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LCMS Application

LEE COUNTY MEDICAL SOCIETY, INC. MEMBERSHIP APPLICATION AND INFORMATION 13770 Plantation Road, Suite 1 Fort Myers, FL, 33912
$100.00

Below is our online application. Please complete all the fields of information necessary for our application process. Once completed and submitted we will review your application and email you the approval notification with further instructions.

If you prefer to submit your applications through snail mail you will find the PDF forms under the attachments tab. Please complete and return to the Medical Society office for processing.

Please be sure when filling out your application that you include all addresses of your practice in Lee County and not your present address outside of Lee County. Addresses must be complete for physician references, association references, medical schools, internships, residencies and other hospital affiliations. Zip codes are needed. By including the above you will speed up the application process.

Pictures:
We will need a professional photo taken within the past year. The photo will be used for the LCMSPictorial Directory, Bulletin, and website. You may mail a photo with your application or email a 1920px x 1080px300dpi resolution file (jpg, png, ai, psd or tif) to the Lee County Medical Society Office.

References:
Once your application has been received your references will be checked. Please allow enough time by sending us your application as soon as possible. Please use only references of your peers (M.D.'s or D.O.'s). Do not use relatives, non-physicians or references in Lee County*. The Society reserves the right to contact anyone who might have an opinion concerning your qualifications. In addition to your application and three photographs, a copy of your Florida Medical License is required. Your continuing Medical Education number from the American Medical Association is required for dues processing. If you do not have this number leave it blank and we will contact the AMA. After favorable action by the Committee on Ethical and Judicial Affairs (EJA) and Board of Governors, your application will be presented to the Membership for their final approval. It is important that you or your office make appointments to interview with two members of the Committee on Ethical and Judicial Affairs (In person or over the phone).

Should you have any questions, please contact the Medical Society office. We will be glad to assist you.

 - Julie Ramirez, Executive Director Lee County Medical Society, Inc.
   Telephone (239) 936-1645

 

*EXCEPTION: A physician practicing in the Lee County area for MORE THAN FIVE YEARS does not have to provide out of town references, but may use four medical references from the Lee County area or outside of Lee County. Two references in Lee County must be Lee County Medical Society members and no more than two references can come from the applicant's immediate practice.

Below is our online application. Please complete all the fields of information necessary for our application process. Once completed and submitted we will review your application and email you the approval notification with further instructions.

If you prefer to submit your applications through snail mail you will find the PDF forms under the attachments tab. Please complete and return to the Medical Society office for processing.

Please be sure when filling out your application that you include all addresses of your practice in Lee County and not your present address outside of Lee County. Addresses must be complete for physician references, association references, medical schools, internships, residencies and other hospital affiliations. Zip codes are needed. By including the above you will speed up the application process.

Pictures:
We will need a professional photo taken within the past year. The photo will be used for the LCMSPictorial Directory, Bulletin, and website. You may mail a photo with your application or email a 1920px x 1080px300dpi resolution file (jpg, png, ai, psd or tif) to the Lee County Medical Society Office.

References:
Once your application has been received your references will be checked. Please allow enough time by sending us your application as soon as possible. Please use only references of your peers (M.D.'s or D.O.'s). Do not use relatives, non-physicians or references in Lee County*. The Society reserves the right to contact anyone who might have an opinion concerning your qualifications. In addition to your application and three photographs, a copy of your Florida Medical License is required. Your continuing Medical Education number from the American Medical Association is required for dues processing. If you do not have this number leave it blank and we will contact the AMA. After favorable action by the Committee on Ethical and Judicial Affairs (EJA) and Board of Governors, your application will be presented to the Membership for their final approval. It is important that you or your office make appointments to interview with two members of the Committee on Ethical and Judicial Affairs (In person or over the phone).

Should you have any questions, please contact the Medical Society office. We will be glad to assist you.

 - Julie Ramirez, Executive Director Lee County Medical Society, Inc.
   Telephone (239) 936-1645

 

*EXCEPTION: A physician practicing in the Lee County area for MORE THAN FIVE YEARS does not have to provide out of town references, but may use four medical references from the Lee County area or outside of Lee County. Two references in Lee County must be Lee County Medical Society members and no more than two references can come from the applicant's immediate practice.

Please complete the Medical Society Application below for processing.

 

Please be sure when filling out your application that you include all addresses of your practice in Lee County and not your present address outside of Lee County. Addresses must be complete for physician references, association references, medical schools, internships, residencies and other hospital affiliations. Zip codes are needed. By including the above you will speed up the application process.

 

Should you have any questions, please contact the Medical Society office. We will be glad to assist you.

 

Julie Ramirez, Executive Director Lee County Medical Society, Inc.
Telephone (239) 936-1645

 

Below is a link for a Lee County Medical Society application. You may either fill out this online application form below and click the "Add To Member Folio" button or complete and return the downloadable form below to the Medical Society office for processing.

Click here to download the LCMS Waiver

 

You must download & read the LCMS Waiver document by clicking the link above. If you accept the terms and conditions please digitally sign your acceptance by completing the downloaded LCMS Waiver and upload the document by clicking the "Upload a file" button below!

If you did not upload the signed LCMS Waiver form above you must enter your full name in the field below to digitally sign your acceptance of the waiver!

When you register for your account at the end of this process please provide your office address in the fields below.

Please Enter below EDUCATION/ Work History (or attached CV)

Please upload your current resume! Please name the file 'YourName_Resume.pdf' !

Medical School

Medical School

Medical School

Medical School

Medical School

Internship

Internship

Internship

Internship

Internship

Residency

Residency

Residency

Residency

Residency

Fellowship

Fellowship

Fellowship

Fellowship

Fellowship

NAME PRACTICES IN CHRONOLOGICAL ORDER (Account for all time since Medical School.)

Other Post Graduate

Other Post Graduate

Other Post Graduate

TWO REFERENCES OUTSIDE YOUR PRACTICE NEED TO BE PROVIDED IF YOU DO NOT HAVE HOSPITAL PRIVILIGES IN LEE COUNTY.

This Communication Consent Statement is intended to fully comply with the Federal Trade Communications Commission Telephone Consumer Protection Act of 1991. I consent to receive communications sent via regular mail, email, telephone or fax by the Lee County Medical Society. I understand this Consent remains in effect as long as I remain a member of the Lee County Medical Society. I PREFER LCMS INFORMATION SENT TO MY FAX# AND/OR EMAIL SHOWN BELOW:This Communication Consent Statement is intended to fully comply with the Federal Trade Communications Commission Telephone Consumer Protection Act of 1991. I consent to receive communications sent via regular mail, email, telephone or fax by the Lee County Medical Society. I understand this Consent remains in effect as long as I remain a member of the Lee County Medical Society.

 
I PREFER LCMS INFORMATION SENT TO MY FAX# AND/OR EMAIL SHOWN BELOW:

Members abide by the AMA Principles of Medical Ethics and the bylaws of the Associations. To assist us in upholding these standards, please provide answers to the following questions, sign and date. If you answer yes to any of these questions, please attach full information.

If 'Yes' please explain. 

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions.

If 'Yes' please explain.

Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?

If 'Yes' please explain.

I am aware that the information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information. I understand that any false or misleading statement made on my application may be ground for denial of membership or probation or censure by, or suspension or expulsion from the medical society (ies). The foregoing information is true and complete.

hobbies, civic organizations, research, family & children activities, travel, mentoring, etc.

The Lee County Medical Society has a New Physician Mentor Program. In this program, we assign a LCMS physician member to help acclimate you to your new community and/or to your new professional association. This will help in establishing new professional relationships for you and your mentoring physician.

Please upload a copy of your FL medical license and a jpg photo in order to process your application.

Please upload a copy of your Florida Medical License in PDF format. Please name the file 'YourName_FLMedicalLicense.pdf'. Please no spaces in file name.

Please upload a recent Photo in PDF JPG format. Please name the file 'YourName_MembershipPhoto.pdf'. Please no spaces in file name.




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