Membership Application - Tennessee Eye Surgeons

Membership Application Form

As a member of the Eye-M. D.s of Tennessee (Tennessee Academy of Ophthalmology), you join your colleagues promoting the profession and speaking for ophthalmology with a single voice.

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Membership Application Form

As a member of Tennessee Eye Surgeons (Tennessee Academy of Ophthalmology), you join your colleagues promoting the profession and speaking for ophthalmology with a single voice.

Benefits of Membership

Protect ophthalmology’s current scope of practice. This is one of the highest and most important priorities for TN Eye Surgeons. Our team works closely with the House of Medicine, other like-minded organizations, and doctors across the state to ensure patients are protected and the public has direct access to medical doctors trained in ophthalmology.

Government affairs work. TN Eye Surgeons employs McMahan Winstead & Richardson for lobbying services. MWR is recognized as a top-tier lobbying firm in Tennessee, and advocates for our profession at the State Capitol.

Coding seminars an Annual Scientific Meeting. Each year TN Eye Surgeons sponsors a coding seminar and annual scientific meeting. Instructors from the American Academy of Ophthalmology (AAO) present the most timely and accurate information. Dues-paying members receive discounted fees, and are also given discounts for additional enrollees. Non-members are not eligible for discounts.

Additional educational programs. Scientific CME and practice management meetings as well as ophthalmology personnel education (technical and front office) continue to be a priority. Dues-paying members receive discounts, and non-members pay up to twice the member rate for educational meetings.

Website and newsletters. Our website, tneyesurgeons.com, and regular newsletter provides critical legislative updates both federal and state, CME opportunities, ways to get involved in advocacy, calendar and events updates, and more. Our newsletter is only available to dues-paying members.

Public and external relations. The TN Eye Surgeons employs Owen Public Strategies, a communications and public relations firm located in Nashville, to assist with communications to dues-paying members, the media, and the public.

Membership Categories(Required)

Active Member - 4 years or more in Practice - $850.00

Active Member - Third Year Out of Residency - $637.50

Active Member - Second Year Out of Residency - $425.00

Active Member - First Year Out of Residency - $212.50

Active - University Full Time Faculty Umbrella Fee Applies (see your Chair for details) - $0

Active - Part Time Member Working < 25 hours per week - $425.00

Associate - Resident or Fellow Member in UT/Memphis Health Science Center and Vanderbilt Eye Institute Training Programs. Complimentary Membership - $0

Contact Information

Name(Required)

First Middle Last Suffix

Email(Required)

Gender(Required)

Male

Female

Date of birth(Required)

Date of birth

Practice Information

Name of Practice(Required)

Other MDs in Practice:

Address of Practice(Required)

Address Suite City State ZIP Code

Tel(Required)

RENEWING MEMBERS MAY STOP HERE. NEW MEMBERS PROCEED BELOW. If you are a renewing member, you do not have to enter any further information and may scroll to the bottom for online payment. If you are applying to become a member for the first time, please fill in all remaining fields below.

Home Information

Address Apt City State ZIP Code

Tel

Medical School

Name of Institution

Address

City State / Province / Region Country

Years

Degree (s)

(MD, DO, etc)

Residency

Name of Institution

Address

City State / Province / Region Country

Years

Fellowship(s)

Name of Institution

Address

City State / Province / Region Country

Years

Area of Study

Director/Chair

Address

City State / Province / Region Country

Years

Area of Study

Director/Chair

Other Training

Address

City State / Province / Region Country

Years

Director/Chair

Specialization

Specialization 1

Comprehensive Ophthalmology

Glaucoma

Cornea/External Disease

Anterior Segment Surgery

Specialization 2

Oculo-Plastics

Pediatrics

Neuro-Ophthalmology

Retina & Vitreous

Other

For our directory: Please list any special procedures you preform, e.g.: LASIK, Corneal Rings, etc.

Licensing & Certification

Is your license to practice medicine unrestricted and valid?

Yes

If no, please explain:

Are You Licensed in Tennessee?

Yes

Date You Began Practicing Ophthalmology

MD: Are You Certified by the American Board of Ophthalmology

Yes

Date of Certification

DO: Are You Certified by the American Osteopathic Board of Ophthalmology

Yes

Date of Certification

Eligible

A current CV is required with your application.

Max. file size: 100 MB.

Restrictions

Are there any restrictions or circumstances that would affect your membership such as a felony record? Denied hospital privileges or voluntary surrender of hospital privileges? Licensed revoked, suspended or have limited license? Or any other information you should disclose?

Yes (Explain fully on separate document and upload below.)

Restriction explaination

If yes above upload explanation

Max. file size: 100 MB.

Signature of Applicant

By signing this application, I acknowledge that the information herein is true, accurate and complete. I authorize any officer, director or staff of the Tennessee Society of Eye Surgeons (formerly TNAO) to review and verify any information I have provided. I understand that any incorrect or false information found in my application is grounds for revocation and if I do not abide by the TNAO Bylaws and Code of Ethics my membership may be revoked.

Print Name

Date

Endorsement by Colleague

Name of Endorser

Name of Applicant

Signature of Endorser

By signing this application, I know or have personal knowledge of the applicant and recommend them for membership in the Tennessee Society of Eye Surgeons (formerly TNAO). Upon request, I am willing to provide any additional information requested or required.

Print Name

Date

Total

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Credit Card

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Credit Card