New Mexico's Health Quality Improvement Organization

NMMRA Membership Application

First Name

Last Name

Credentials
M.D.		D.O.

Address

City

State

Zip Code

Telephone

Fax

E-Mail

Specialty

Board Certification

Certification/Recertification Date

In active practice?
Yes		No

Hospital Privileges (list)

Peer Reviewer
	Yes, I would like to participate as a NMMRA physician peer reviewer (you must be in active practice.)

My membership will ensure equal representation and participation of the medical profession in NMMRA activities. I understand that membership in NMMRA is open to all doctors of medicine and osteopathy who hold an unrestricted license to practice in the state of New Mexico. Furthermore, I understand there are no dues for membership, and I understand that I may terminate my membership at anytime by notifying NMMRA in writing.