Group Billing and 100% Club Application

1.  * We Want to Participate!
2. Group Name
3. Fax #
4. Contact Information:
   * First Name:  
   * Last Name:  
   * Email Address:  
   * Street 1:  
      Street 2:  
   * City:  
   * State:  
   * Zip Code:  
   * Phone Number:



For Group Billing

I understand that this will allow me to pay all of my physician’s annual ACEP membership dues on one group bill and will allow them to have a common, annual renewal date. I also understand that in some cases some ACEP memberships may be prorated to accommodate the group billing process. Please enter your emergency physicians and their ACEP member ID (if known) below.

5.  * I would like to pay:
6,   I would like to pay my group bill beginning:
For the 100% Club
All eligible emergency physicians in your group must be members. To help us determine your eligibility for this program, send an email by clicking here and attaching a list of all of your emergency physicians and their ACEP member ID numbers (if known).


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