LMGMA Membership Application

ACTIVE MEMBER: Louisiana resident primarily responsible for medical practice management in physician and medical group practices.
ALLIED MEMBER: Louisiana resident employed in setting such as hospital, school, medical society, PHO, MSO, PT practice, home health service, or ancillary service.
AFFILIATE MEMBER: Includes exhibitors, bankers, attorneys, CPAs, vendors, and sponsors.
STUDENT MEMBER: Fulltime student in healthcare administration program in accredited university.

Applying as:
Active $100 | Allied $100 | Affiliate $225 | Student (Free)
Member Information:
Full Name

Job Title

Email Address
Phone
I am a member of National MGMA
I am a member of ACMPE:
Nominee | Certified | Fellow
Affiliate Member: What is the primary purpose of your company?
Practice Information:
Practice Name
Specialty
Address
City
State
Zip Code
Phone
Fax
Website
Full Time Physicians
Part Time Physicians
NP
PA
Other
Total Employees
Software:
Do you have an electronic medical records system?
Which system do you have?
Medicaid / Medicare:
Medicaid
Number of your providers who accept Medicaid patients
Medicaid
% of your patients who are Medicaid
Medicare
Number of your providers who accept Medicare patients
Medicare
% of your patients who are Medicare
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Photographs are taken at our conferences and workshops and could be used in corporate newsletters, on the LMGMA website, and brochure advertising. Your enrollment as a member and signature on this form grants permission for this activity.
Member Signature