Membership Application Form

Membership is open to any organization whose mission is consistent with the mission and vision of the Michigan Primary Care Consortium. Please be sure you are familiar with MPCC membership requirements prior to submitting your form. Membership requirements are listed under the Member Benefits & Responsibilities tab.

Name of Organization: *

Organization Type (Coliapsible)

Industry/Type of Organization: *

Professional and Trade Association

Insurance Company and Health Plan

Health Systems

Federally-Qualified Health Center/Community Health Center

Consumer Organization

Regional Health Initiative

Public Health Organization

Government

Business

Academia

Physician Organization/Physician-Hospital Organization

Primary Care Practice

Other

If 'other' please specify:

Organization Address: *

Executive Level Decision-Maker: *

Telephone: *

Fax:

Executive Level Decision-Maker Signature: *

(By typing your name, you authorize membership application and agree to full-filling all membership requirements.)

Please identify the INDIVIDUAL who will represent your organization on the Michigan Primary Care Consortium:

Name of Organization Representative: *

Address: *

Telephone: *

Fax:

E-mail Address: *

Optional: You may also identify an alternate individual who will represent your organization on the Michigan Primary Care Consortium in the absence of your primary representative:

Name of Alternate:

Address:

Telephone:

Fax:

E-mail Address:

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MPCC Michigan Primary Care Consortium - P.O. Box 30195 - Lansing, Michigan 48909 - (517) 241-7353

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