ACP Reinstatement Form For Members, Fellows and Physician Affiliates

* Required field

Contact Information

ACP ID

Date of Birth *

Month

Day

Year

First Name *

Middle Initial

Last Name *

Address 1 *

Address 2

City *

State/Province *

Zip/Postal Code *

Country *

Phone Number *

Fax Number

E-mail *

Recruiting Information

If an ACP member recruited you, please list his/her name:

Recruiting member ACP ID (if known)

Annual Dues

To Ensure Membership through June 30, 2020 [i]

Priority Code

Priority codes allow us to administer special offers, discounts, and help us determine which of our products and services are of most value to you. Priority codes are listed on ACP print promotions and some electronic promotions. The priority code is indicated clearly within written text or on the mailing panels of most forms near the ordering information. Entering a priority code will help us meet your future needs.

Payment Code

Members and Fellows - United States [ii] *

Eight or fewer years out of medical school

Nine or more years out of medical school

Dues Amount * $

[i] Membership dues rates are pro-rated throughout the membership year. The dues you are charged will be contingent upon the month you reinstate. The allocation of chapter dues is waived for newly reinstated members. Upon membership renewal, annual dues will include fees to support both the national ACP and your local chapter. For the renewal dues rate in your chapter, please visit https://www.acponline.org/dues.

[ii] Physicians outside of the United States should contact ACP Member and Product Support for reinstatement rate options.

Agreement

I affirm that all medical licenses granted to me are in good standing, and that I have not been the subject of disciplinary action.* I understand that, in order to evaluate my request for reinstatement, ACP will review my credentials. I agree to cooperate in such a review and allow others to provide information regarding my credentials. To the best of my knowledge, all information furnished by me in this request and in any supporting documentation is true and complete. I have read the ACP Pledge and affirm that I will uphold the ethics of medicine as exemplified by the standards and traditions of the College

*If you have been subject to disciplinary action, please contact Member Credentialing at 800-523-1546, extension 2704 or 215-351-2704 or by email at help@acponline.org.

Payment Details

Once you submit this form, ACP Member and Product Support staff will contact you by email to complete your request and to process your membership dues payment.