Membership Application for Physicians

Membership Application for Physicians

You can fill out this online form or download, print and send a hard copy to:

Charles Cassidy, MD

750 Washington Street

Box 26

Boston, MA 02111

p-617-636-5150

f- 617-636-5178

Email any questions to This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Membership Application for Physicians

PART I: PERSONAL DATA

Enter Full Name: *

Business Address
Include: Address, City, State & Zip *

Home Address:
Include: Address, City, State & Zip

Fax:

Work Phone:

Home Phone:

Email Address: *

Preferred Mailing:

Work Home

You automatically qualify for membership in the NEHS if you have received your Certification of Added Qualifications in Surgery of the Hand. Please provide the date of certificaiton and attach a photocopy of your CAQH.

Date of Certification

PART II: PROFESSIONAL QUALIFICATIONS

1. PRACTICE DESCRIPTION

Current Practice Location:

Percent of caseloads in hand/upper extremity:

Previous Practice Location:

2. CREDENTIALS

Undergraduate Institution:

Degree/date:

Medical School:

Degree/date:

Dates:

Internship:

Residency:

Dates:

Fellowship:

Dates:

Board Certification(s):

Date(s):

State Licensure:

Number:

3. TEACHING AFFILIATIONS

Names and dates:

4. PRESENTATIONS/PUBLICATIONS/TEACHING EXPERIENCE (last 4 years)

Names and dates:

5. MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS

Names and dates:

6. LETTERS OF RECOMMENDATION

Names and dates:
Submit two letters of recommendation from physician members of the NEHS. List their names and addresses then mail them to NEHS.

PART III: DISCIPLINARY ACTION(S)

Are you currently under investigation by any professional organization or licensing board?

YES NO

Has your medical license ever been suspended or revoked?

YES NO

If Yes
If you answered yes to either of the above, please provide a detailed explanation:

CV
Please attach a copy of your most recent CURRICULUM VITAE with this application.

I attest that the aforementioned replies are true and accurate. If I become a member, I hereby agree to comply with the Constitution and By-Laws of the New England Hand Society, and further agree to pay all dues and assessments promptly.

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