AAHIVM Join Online : Membership Application

Regular Membership: $175.00
Student Membership: $25.00

Memberships are valid from the month of enrollment for the next 12 months.

*Required information

Downloadable Application (PDF) or Renewal Form
Download Adobe Acrobat Reader

Choose a membership type: Primary Affiliate Student
and: New Renewal
  Primary: MD's, DO's, PA's, NP's
  Affiliate: All other degrees
  Student: Those currently enrolled in a training program.

*First Name:
*Last Name:
*Professional Degree: MD DO NP PA DDS PhD PharmD Other


Office Address: (will be displayed in your online profile)
Institution
*Street: Address 2: Region/Province:
*City: *State: Country:
*Zip Code:
*Phone: ext.: Fax:

Professional Profile Information: (This information will be available to the public on our website under the "Search for a Provider" function.)
1) What office hours do you see HIV Patients?
                 Monday Tuesday Wednesday
  Thursday Friday Saturday
  Sunday
2) Please list up to three hospitals that you admit patients to most frequently

1.

2.

3.


Information for your Academy membership record: (will NOT be displayed in your online profile)
Home Address
*Street Address 2 Region/Province
*City *State Country
*Zip Code
*Phone
*Professional Email:
Business Manager/Assistant Email:  


1) How many HIV patients are under your direct care? 1-25 26-75 75-150 150+
2) Do you or your agency receive Ryan White CARE Act funding? Yes No
3) Is your practice or agency a Medicaid provider Yes No
4) What is your license #
5) Which of the following best describes your race or ethnicity?
       Please specify your race or ethnicity if you selected Other:
6) Sex:
7) What is your principal employment setting
       Please specify your employment setting if you selected Other:


8) Yes I would like to participate in future market research programs conducted through the Academy. I understand I may be compensated for such research, and all my responses will be kept confidential and reported anonymously.
9) Periodically we may make our mailing list avilable to other interests. Please check this box if you DO NOT wish your professional address to be shared with others.
*10) I agree to AAHIVM's Ethics Policy
*Payment Information: Regular Academy membership is $175.00 for a twelve month period starting at the month of enrollment. Student membership is $25.00. Membership in the Academy includes automatic enrollment as a member of your state/regional chapter and all membership benefits. (Student discount requires a letter of trainee/students' supervisor.)

You can pay for your membership with MasterCard, Visa, American Express, or Discover Card. This is a secure transaction.

I will mail my check for my membership payment I will pay online with my credit card

AAHIVM Fundamentals of HIV Medicine is a renowned clinical reference. Additional information about this publication is available at www.AAHIVM.org. Domestic shipping is included in the prices below. There are additional charges for international shipping of the publication.

I am an AAHIVM member - please ship copies of Fundamentals of HIV Medicine @ $150.00 per copy.
I am NOT an AAHIVM member - please ship copies of Fundamentals of HIV Medicine @ $225.00 per copy.