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Be a TMA Member Today!

By completing and submitting your information, you are applying for membership in the Tennessee Medical Association. Once your application is received, your status will be ‘pending’ and awaiting approval by the local medical society in your area. During this time you will be afforded full access to member services, benefits and staff assistance. Upon acceptance, you will receive a statement for your annual membership dues. If you have additional questions about the membership process or your benefits and rights, please contact our membership department at 800-659-1862 or via email at membership@tnmed.org.

Membership Application

Required fields are marked with an asterisk (*). We will not be able to process your application unless the required fields are filled.

 

Step 1: Personal Information
First Name: *
Middle Name:
Last Name: *
I am a(n): *
Credentials: 
Marital Status:
Maiden Name:
Spouse's Name:
Gender:
 
Birth Date: *
SSN#:
NPI#:
TN Medical Lic.#:
Date of Issue:
Step 2: Contact Information
Office Address *  

Street/PO Box: *

If you're a student or resident and you don't have a primary office street address, enter "Student/Resident" in this box.
City: *

If you're a student or resident and you don't have a primary office city, enter "Student/Resident" in this box.
State: *
Zip: *

If you're a student or resident and you don't have a primary office zip code, enter your home zip code in this box.
Practice/Group Name:
Office Phone:
Office Fax:
Home Address *  

Street/PO Box: *
 
City: *
 
State: *
 
Zip: *
 
Home Phone:
Email: *
Please check the preferred address for TMA correspondence: *

Step 3: Education and Training

Specialty: 
Subspecialty:
Medical School: *
Residency:
Name of institution, city, specialty, degree
Fellowship:
Name of institution, city, specialty, degree
Board Certification(s):
Boards and dates
Graduation Year:
Step 4: Agreement
Have you ever been convicted of a felony crime? *

If yes, what was the reason?
Has your license to practice medicine in any jurisdiction been limited, suspended or revoked? *

If yes, what was the reason?
I agree that all statements are true and complete to the best of my knowledge and belief. If elected to membership, I agree to conduct myself professionally and personally according tot he principles of medical ethics and be governed by the Constitution and bylaws of the component medical society, the Tennessee Medical Association, its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives concerning my professional competence, ethical conduct, character, and other qualifications for membership. In addition, by submitting your addresses, phone numbers and email, you give Tennessee Medical Association permission to correspond with you through these channels. 
Check this box to show your agreement with the above statement. *
Clicking submit will email you a copy of this completed form. Please review and inform us of any inconsistencies and keep a copy for your records.