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Membership Application
(For Physicians & Medical Students)
Full Name:
Practice/School Name:
Email:
Cell:
Spouses Name:
Spouse's Email:
Are you a practicing physician in the State of South Carolina? (Yes or No)
If so, in what county do you practice?
South Carolina Medical License Number:
Is your degree an M.D. or D.O.?
Are you a resident physician in training in Florence County? (Yes or No)
Are you a medical student performing part of your medical training in Florence? (Yes or No)
If so, name the Medical School in which you are enrolled.
The address where you currently live:
Is Your Spouse a Physician/Resident Physician/Medical Student ?
Yes
No
Mailing Address
City, State, and Zip Code:
*Billing address for dues, if different from mailing address above.
Please include the name/phone if there is an individual in your office responsible for paying your dues.
If you are an employed physician, you can apply your CME allowance to FCMS membership dues.
McLeod Health and HopeHealth will pay membership dues directly. If you prefer for your membership dues to be paid directly by your employer, please check the appropriate box below.
*If you are employed by MUSC, payment needs to be made by the individual directly to FCMS. The receipt can then be submitted to MUSC HR for reimbursement (FCMS will provide you with an appropriate receipt).
McLeod Health Employed Physician
HopeHealth Employed Physician
Please bill my employer automatically for my dues each year (you can request to stop this at any time).
Membership Dues (includes spouse if married) (Please check one).
Does not include
SCMA
or
AMA
membership.
Practicing Physician / Physician couple - $210
Retired Physician - $110
Resident Physician or Medical Student - No Charge
Widowed - $60
*Please note: When you click the "Submit Application" button below, you will be taken to a success tab to pay your membership fees.
By submitting this form you agree with our
Privacy Policy
Thank You!
Your submission has been received! Please click the button below to pay your membership dues.
Type of membership
Active Physician or Physician Couple $210.00 USD
Retired Physician $110.00 USD
Widow or Widower $60.00 USD
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