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The AFA Professional Practices Network Form

Below is our Professional Patient Care Network Form. By becoming a Professional Member and joining The AFA’s Professional Patient Care Network, you will become a part of a community of fertility specialists dedicated to helping men and women create families. As a professional member, you will be listed on our website, as well as in our National Infertility and Adoption Resource Directory and receive professional membership acknowledgment in our weekly e-newsletter, Connect. You will have an affiliation with an organization that patients turn to regularly for help in locating health care professionals.

Yearly Professional Membership fees are outlined below:

Silver Professional Membership with 1-3 professionals - $600
Gold Professional Membership with 4 - 6 professionals - $1200
Platinum Professional Membership with 7 or more professionals - $1600

We will ask applicants to update the information about their practice periodically to make sure that this information remains current. Please contact Lisa Van Ness at (888) 917-3777 if you have any questions about the Professional Patient Care Network Form.

Name:

Practice:

Primary Office Address:

City:

State:

Zip:

Business Phone:

E-Mail:

Web Address:

Names of Associates:

Additional Offices:

Practice:

ART Program Affiliation:

ART Program Address:

Hospital Affiliations:

Specialty Area For Resource Directory Listing:

Please Check All That Apply To Your Specialties or Services Performed at Your Practice:
NATIONAL PROFESSIONAL LISTINGS
Acupuncture
Adoption Agency
Attorney
Complementary Medicine
Consultant
Egg Donation Agency
Geneticist
Insurance Companies
IVF Practice
Male Factor Infertility Testing
Mental Health Professional
OB/GYN
Pediatrician
Pharmacy
Reproductive Endocinologist
Sperm Bank
Sperm Donation Agency
Surrogacy Agency
Urologist

Please describe the services that you provide.

Please list all services that you or your agency offer:

Are you a participant in any managed care plans?

Do You Treat Patients On A Fee-For-Services Basis?

Education and Experience

Enter details of degree obtained

School:

Degree:

Year:

Enter details of degree obtained

School:

Degree:

Year:

License or Certificate

License/Certificate:

State:

License/Certificate #:

License or Certificate

License/Certificate:

State:

License/Certificate #:

License or Certificate

License/Certificate:

State:

License/Certificate #:

Other Training

Organization:

Year:

Other Training

Organization:

Year:

Are you a member in good standing with your State Board in your field?

If no, please explain:

Enter State Boards

Board:

State:

Board:

State:

Professional Organizations:

Professional Member of The AFA
American Society for Reproductive Medicine
National Certification Board for Therapeutic Massage and Bodywork
National Certification Commission for Acupuncture and Oriental Medicine

Other professional organizations:

I acknowledge and agree that my inclusion or removal from The AFA Professional Patient Care Network is at The AFA's sole discretion. Furthermore, in consideration of my inclusion on the list, I agree to indemnify, defend and hold The AFA harmless in the event a patient referred to me by The AFA makes a claim against The AFA, its directors, employees, members and volunteers, in connection with services rendered by me or my practice.

I understand that I will become a Professional Member of The AFA and will be invoiced for my level of membership accordingly.

The American Fertility Association's Professional Networks are supported by a sponsorship grant from National Fertility Law Center.