OOSS Outpatient Ophthalmic Surgery Society

OOSS Member Application 2009

*Fee:

	$1,500.00 USD - Facility Membership (1-9 members) fewer than 1,000 procedures per year.
	$2,500.00 USD - Facility Membership (1-9 members) more than 1,000 procedures per year.

*Primary Member:

Name	Degree	Email


President's Council Donor?

PRIMARY ASC FACILITY

*Name:

*Address:

*City:

*State: *Zip:

*Phone:

Fax:

BILLING CONTACT & INFORMATION

*First:

*Last:

*Address:

*City:

*State: *Zip:

*Phone:

*Email:

President's Council Donor?

ASC FACILITY ADMINISTRATOR

*First:

*Last:

*Address:

*City:

*State: *Zip:

*Phone:

*Email:

President's Council Donor?

ASC FACILITY MEMBER INFORMATION (Additional persons to be included in this membership)

Physician Member:

Name	Degree	Email


President's Council Donor?

Physician Member:

Name	Degree	Email


President's Council Donor?

Physician Member:

Name	Degree	Email


President's Council Donor?

Physician Member:

Name	Degree	Email


President's Council Donor?

Physician Member:

Name	Degree	Email


President's Council Donor?

Any member with a degree of Doctor of Philosophy, RN, or of professional standing, and engaged in a field allied to ophthalmology.

Associate Member:

Name	Degree	Email


President's Council Donor?

Check Box to Enter Multiple Practices/Facilities

SECOND ASC FACILITY
Name:

Administrator:

Billing Contact:

Address:

City:	State: Zip:

Phone:	Fax:


THIRD ASC FACILITY
Name:

Administrator:

Billing Contact:

Address:

City:	State: Zip:

Phone:	Fax:


FOURTH ASC FACILITY
Name:

Administrator:

Billing Contact:

Address:

City:	State: Zip:

Phone:	Fax:

Total
$ USD

* Indicates Required Fields

Other pages in this section:

Inside OOSS

History of OOSS

Governance

Bylaws

Join or Renew OOSS Membership

Apply Online!

2009 Member Application

OOSS-Endorsed Services

ASC ADVOCACY CENTER

JOIN OOSS ONLINE

ASC RESOURCES

ASC QUALITY AND EFFICIENCY

HEADLINES

PROGRESSIVE OPHTHALMIC
ASC REGIONAL MEETINGS

2008 MEDICARE
ASC RATE SCHEDULE

YOUR CareerHQ