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Membership Inquiry
Please fill out this form to inquire about membership.
Name
*
Phone
*
Email
*
Type of Practice
*
Years Active
*
Are you board certified?
*
Yes
No
Are you out of network with all commercial insurance companies?
*
Yes
No
Brief Description About Your Practice
*
How did you hear about our organization?
*
Were you referred to IDNY by a member? If, so please let us know who.
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