Florence County Medical Society & Alliance

Membership Application
(For Physicians & Medical Students)

Name:

Practice/School Name:

Email:

Cell:

Spouses Name:

Spouses Email:

Is Your Spouse a Physician/Resident Physician/Medical Student ?

YesNo

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 PhysicianHopeHealth 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 - $210Retired Physician - $110Resident Physician or Medical Student - No ChargeWidowed - $60

*Please note: When you click the "Submit Application" button below, you will be taken to a success tab to pay your membership fees.

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Membership Application(For Physicians & Medical Students)

Membership Application
(For Physicians & Medical Students)