Become a Member

You’ve already taken the first step to becoming member. After all you’ve found your way here. The rest of the process is simple.

JOIN US.

Take a few moments to complete the brief membership application.
You will be contacted by a member of the membership team and provided additional information and instructions for submitting your membership dues.
Activate your membership through our convenient online payment portal or by one of our other payment options.

QUESTIONS? Contact Laura Polak or call 402.393.1417.

NOTE: Requirements for membership eligibility:

Physician with MD, DO or equivalent or individual currently attending medical school, in residency or fellowship.
Must practice or live in metro Omaha area
Must be licensed to practice in the State of Nebraska (or be licensed to practice medicine in Iowa if the practice location is in Iowa)

"*" indicates required fields

Personal & Contact Information

First Name*

Middle Name*

Last Name*

Credentials (MD, DO, PhD, etc.)

Please select one.*

Medical Student

Resident

Fellow

Practicing Physician

Retired Physician

Birth Date*

Gender

Male

Female

Your Email*

Clinic/Group Name

Office Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone

Practice Manager Name

Practice Manager Email

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Referred by:

How did you hear about us?

Educational & Professional Information

Medical School

Medical School Graduation or Anticipated Graduation Date

Residency Location

Residency Completion Date

Fellowship Location

Fellowship Start Date

Fellowship Completion Date

Primary Specialty

Secondary Specialty

By submitting this form, you are certifying that the information provided in this application is accurate and complete to the best of your knowledge.

Phone

This field is for validation purposes and should be left unchanged.

JOIN US.

Personal & Contact Information

Educational & Professional Information

Membership

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