CPALTC Membership Form | Carolinas Society for Post-Acute and Long-Term Care Medicine

Membership Type *

NEW

RENEWAL

Online Membership Application: You can register to become a member or renew your CPALTC membership online. Please complete the fields in the membership application below and then click on the submit button. You may either send a check to: : Physicians Eldercare 4692 Brownsboro Road Winston-Salem, NC 27106 or click on the PayPal button to pay by credit card or PayPal. If you have any questions about membership, please contact CPALTC at : taclements@novanthealth.org

Credentials *

e.g. MD, NP, PA, RN, etc.

First Name *

Last Name *

Degree

Address *

Address 2

City *

State *

Zip *

Phone *

Email Address *

CPALTC will not share your e-mail, we will only use your e-mail to contact you about CPALTC.

Physician Membership ($100): Any physician licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote, to be elected to the Board, and to hold office.

NP or PA ($50): Any advanced practitioner (NP, PA) licensed in North or South Carolina whose professional medical services are provided in part within post-acute or long-term care facilities in North or South Carolina. Eligible to vote and to be elected to the Board.

Affiliate ($50): This would include the IDT (Interdisciplinary Team i.e. Administrators, therapists, pharmacists, DON, RN) and LIPs (Licensed Independent Practitioners i.e. DDS, CNS, DPM) and Industry. Affiliate members may attend and speak at membership meetings but are not be eligible to vote or hold office.

Student (free): Fellows, Residents, Post Graduate or Undergraduate Medical, Nursing or Other Healthcare Programs. Student members may attend and speak at membership meetings but are not be eligible to vote or hold office.

Individual Membership *

Physician: $100

NP/PA: $50

Affiliate: $50

Fellows/Residents/Students are free

Committees

I am interested in working on the committee(s) as created by the Board such as Education, Membership, Newsletter, and Public Policy.

Payment Method: *

PayPal

Check to CPALTC

Please select which payment method you will use for your membership dues. If you will be paying online you will need to complete the payment information which will be presented on the next screen after you submit this membership application data form.

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