AAP Enterprise Membership Interest Form

AAP Enterprise Membership (EM) is a multi-year partnership with AAP National, State Chapters, and specific types of pediatric organizations. All member-eligible physicians in the organization join both AAP National and Chapter. EM offers member benefits/services for both individuals and organizations.

Please complete this form if your organization is interested in participating in the EM program.

To learn more about EM, please access this short deck.

Name of Organization *

City *

State *

Name of Primary Contact (e.g. pediatric department chair, division chair, CEO, etc.) *

Primary Contact Email *

Primary Contact Phone *

Name of Support Contact (point person for processing EM) *

Support Contact Email *

Support Contact Phone *

How would you describe your organization (select all that apply)? *

Academic institution or pediatrics department within an academic institution (with an ACGME accredited residency program)

A Children's Healthcare Foundation

A Non-Academic Children's Hospital

An Independent Physician Association (IPA)

An Independent Practice Association (IPA)

A Clinically Integrated Network (CIN)

Other Other

Is your organization privately incorporated? *

Yes

What is your organization's relationship to any children's hospitals? (please describe)

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Does your organization do any type of resident training? *

Yes

Please describe

How many member-eligible physicians are in your organization? *

After eligibility is determined, the next step is to provide a complete roster of all member-eligible physicians so that we can complete a membership analysis and price estimate. Note: NPs and PAs can be included, but they are not counted as part of the 100% membership requirement for the deepest discount. In order to do the analysis, we need first name, last name and birthdate for everyone on the roster. Are you able to provide this information? *

Yes

No *If no, please tell us what information you can provide (i.e. email, etc) No *If no, please tell us what information you can provide (i.e. email, etc)

With EM, a single bill/invoice is created for everyone in the EM. Is your organization able to handle a centralized billing process? *

Yes

No *If no, please explain No *If no, please explain

Is there anything else we should know about your organization?

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Once submitted, your information will be forwarded to the AAP Member Value and Engagement Committee (MVAEC) to determine eligibility. We will reach out to you within two weeks regarding next steps.

Questions about this form? Contact Janet Henderson (jhenderson@aap.org).