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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
Hypnotherapist
Insurance Companies
IVF Practice
Male Factor Infertility Testing
Mental Health Professional
OB/GYN
Neurology
Pediatrician
Pharmacy
Children's Reference Material
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.