Application for Membership

Name
Degree
License Number
State
   
Select a Membership Category from the options below:

Regular: Active $250 per year
 

MD/DO, DDS/DMD, NP, PA who holds a valid license to practice his/her profession in the U.S.

Regular, active membership applicants, please enclose application fee of $25.00, and a photocopy of your current license. (If you wish to enclose your dues, no application fee is required.)

   
In-Training Active $150 per year
  MD/DO, DDS/DMD, NP, PA who participates in a valid medical, surgical, or dental training program.

Members in-training, please indicate the anticipated duration of your training and its location.
   
   
   
   
Corresponding $150 per year
  A licensed foreign physician
Corresponding, (foreign) applicants, please include a copy of your license.
   
Student $20 per year
  A matriculant in good standing in an accredited school of medicine, osteopathy, or dentistry with an interest in homeotherapeutics.
Student membership applications, please include copy of student I.D. card.
   
Credit Card Visa    MasterCard   Discover
Card Number

 

Signature

 

X___________________________________________

   
Professional Information  
Office Address
City / State / Zip Code
Telephone Number
Fax Number
E-mail Address
   
Home Information  
Home Address
City / State / Zip Code
Telephone Number
E-mail Address
   
Please List Degrees
 
 
 
Are you Board Certified? yes no
Board of Certification
   
The AIH publishes a directory of our membership. Please indicate what of your office information should not be published. Your home information will not be published, but provided only to AIH members.
   
I agree to having the above office information except where indicated published in the
AIH Directory of Members and/or on the AIH website.
   
Signature

X______________________________________________

   
Applicants for Corresponding or Student membership may stop here after signing above.
   
Professional domestic applicants are asked to answer the following questions:
   
yes no Are you prepared to practice homeotherapeutics in accordance with the AIH Standards of Practice?(see Standards)
yes no Have you listed a physician reference?
yes no Have you been convicted for fraud or a felony within the last five years? *
yes no Has any action, in any jurisdiction, been taken regarding your license to practice medicine within the last five years or extending to within the last five years? This includes actions involving revocation, suspension, limitation, probation, or any other sanctions or conditions imposed upon a license.*
yes no Have you been the subject of any disciplinary action by any medical society or hospital staff within the last five years? *
  * (If you answered yes to noted questions, please attach full information.)
   
Conviction for fraud or a felony, or actions involving revocations, suspension, limitation, probation, or any other sanctions or conditions imposed upon a license to practice medicine or disciplinary action by any medical society or hospital staff, after due notice and hearing, may result in censure, suspension, or expulsion of a direct member. The Health Care Quality Improvement Act requires professional societies to report certain professional review actions that adversely affect membership, including denial of membership, to the National Practitioner Data Bank.
   
Please list a professional reference with telephone number below:
Name
Address
City / State / Zip Code
   
Signature X______________________________________________
To the best of my knowledge, I have answered the above questions fully and honestly. I agree to abide by the By-Laws of the American Institute of Homeopathy, to pay all dues, fees and assessments in a timely fashion, and to conduct my practice in an ethical manner.
   
Signature X______________________________________________
   
Office Use Only:
Date Recieved_____________ License Verification________________
Newsletter, 30 days_________________________ Journal________________________
Letter, Certificate, Membership Card______________________
Return Application to address below. Call with any questions.
 
American Institute of Homeopathy
c/o Sandra M. Chase, MD, DHt, Trustee
10418 Whitehead St.
Fairfax,Virginia 22030
Telephone: (888) 445-9988