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APPLYING FOR MEMBERSHIP

This is a secure form.  KCMS Membership applications are processed quarterly. Please review the application requirements before starting.  Your medical license number, educational information and three (3) KCMS references are required. 

When your application is complete, click the PRINT button at the end of the form to print a copy for your files before you click the SUBMIT button to send your application to us. You will receive automatic email notifications updating the status of your application.

For instructions on sending your photograph, please refer to the section at the end of this form. A printable application form is also available for those who wish to apply by mail.

Thank you.



Download an Application 

 

 

Online Membership Application

* indicates a required field
Personal Information
* First Name
 M Initial
 * Last Name
 * Social Security Number
Name of Spouse
* Degree
 * Birth Date
 * City, Country of Birth
 * Gender
 * U. S. Citizen?
Home Address
* Home Address 1
 Home Address 2
* City
* State
* ZIP Code
* Publish my home address in the Roster and on the Website: Yes    No
      (Please note: Your home address will only be visible on the website to your colleagues.)
* Home Phone
* Email
* Publish my email in the Roster and on the Website: Yes    No
      (Please note: Your email address will only be visible on the website to your colleagues.)
In what languages are you fluent other than English?    Language 1:    Language 2:
Practice Information
Primary Office Type of Practice:
* Office Address 1
 Office Address 2
* City
* State
* ZIP Code
* Office Phone
Office FAX
Website URL
 
Secondary Office Type of Practice:
Office Address 1
 Office Address 2
City
State
ZIP Code
Office Phone
Send Mail To:
Medical Licensing, Specialty, Education
* Washington State License#:     * Year:
License State #2: License#: Year:
License State #3: License#: Year:
* Primary Specialty
Secondary Specialty
     OR Special Interest
    
Other Specialty
     OR Special Interest
    
* Practicing in King County as of     * First year of practice? Yes   No
* Medical School
 * Year Graduated
 * State
* Internship Location
 * Year Began
 * Year Ended
 * State
 * Specialty
* Residency Location
 * Year Began
 * Year Ended
 * State
 * Specialty
Additional Residency or Fellowship Location
   Year Began
    Year Ended
    State
    Specialty
Additional Training Location
   Year Began
    Year Ended
    State
    Specialty
Additional Training Location
   Year Began
    Year Ended
    State
    Specialty
Applies to foreign medical school graduates:
          ECFMG Certificate #    Date issued
* PRACTICE EXPERIENCE - List in chronological order all previous practice experience.
      (If there is a break in time due to military, pregnancy, etc., please include the time frame.)
* PROFESSIONAL ORGANIZATIONS - Please list professional society memberships
      (i.e. AMA, WSMA, specialty, etc.)
* Are you transferring from an AMA component medical society? Yes   No If yes, which one?
* Has your license to practice medicine in any jurisdiction ever been limited, suspended, revoked, denied, not renewed, or have proceedings toward any of those ends ever been instituted? Yes   No      (If yes, list details below:)
* Have your privileges at any hospital ever been suspended, denied, diminished, revoked or not renewed? Yes   No
      (If yes, list details below:)
* Are there any medical malpractice actions in this or any other state pending against you presently? Yes   No
      (If yes, list details below:)
* Have any judgments or settlements been made against you in professional liability cases in the last 10 years? Yes   No
      (If yes, list details below:)
* Have you ever been denied professional liability insurance or has your policy ever been cancelled? Yes   No
      (If yes, list details below:)
* REFERENCES - Names of three KCMS members are required

Please read the following legal terms of application and check the box at the bottom if you accept.

RELEASE FOR MEMBERSHIP TO KING COUNTY MEDICAL SOCIETY

In consideration of the King County Medical Society processing my application for membership, I grant permission and consent for you to obtain from all hospital affiliations, information regarding staff privileges, and actions relating thereto; and all information from former medical society affiliations, specialty organizations, the American Medical Association and the Washington State Medical Association, medical schools and other organizations providing medical training including internship and residencies.

I agree to furnish the Society with all information relative to any claim or action filed against me for malpractice, and I authorize and consent for you to obtain from my insurance malpractice carrier any and all information regarding insurance coverage, premiums, claims, and actions against me.

I further authorize disclosure of information generally considered to be reliable which has a bearing on my professional competence, character, and ethical qualifications to all hospitals, and medical licensing or discipline boards who request such information.

I hereby release, and hold harmless from any liability or loss, the King County Medical Society, Inc., its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the Medical Society, or to its authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.

I further release from liability the King County Medical Society, Inc., its officers, agents, employees, and members for the delivery of information to any third party as authorized herein, provided such delivery occurs prior to the acknowledged receipt, in the office of the King County Medical Society, of a written notice or revocation of this release.

I hereby agree to abide by the By-Laws and the Principles of Medical ethics of the KCMS and agree upon election, that my membership in the KCMS shall be conditional upon continued compliance of the aforementioned; and I further agree to recognize and abide by the interpretation thereof by the authorized officers of the Society, reserving all rights of appeal as set forth in the By-Laws of this Society.

I HEREBY AFFIRM AND REPRESENT THAT ALL STATEMENTS, ANSWERS, AND INFORMATION CONTAINED IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I accept the terms stated above.
PRINT A COPY OF YOUR APPLICATION FOR YOUR RECORDS
   


HOW TO SEND US YOUR PHOTOGRAPH

A recent photograph is required with your application. You can send one by mail or electronically.

  • Send by mail to: KCMS, 200 Broadway, Seattle WA 98122.
  • Send electronically to: photos@kcmsociety.org
  • Specifications:
    • A portrait black/white or color photo
    • JPG or TIF format, 300 dpi resolution
    • Photo size does not need to exceed 5”x7”

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