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Confidential Request for Dues Adjustment

Note: Fields marked with * are required.

Please remember to make a copy of this form for your records

*Name:

*ACP ID #:

*Address:

*City:

State/Province:

ZIP/Postal:

Country:

*Contact Number:

*E-mail:

Please indicate the type of dues adjustment being requested:

Disability (Permanent/temporary adjustment)
Medical condition that seriously interferes with the ability to practice medicine and/or earn income.
Please indicate:

  1. Permanent condition (personal physicianís note required)
    Temporary condition (temporary reduction only, renewable annually upon request)

  2. Dues reduction (with publications)
    Dues waiver (no publications)

  3. Medical condition:

  4. Impact on employment:

  5. Anticipated date of return to employment:
    Full time
    Part time



Financial Hardship (Temporary adjustment, renewable once upon review)
Sudden, unforeseen short-term financial difficulty resulting in substantial reduction of income.
Please indicate:

    Dues reduction (with publications)
    Dues waiver (no publications)

    Please describe the circumstances for requesting this adjustment and how long and to what degree this will affect your ability to pay dues:



Retired/Semi-retired (Permanent adjustment, no renewal required)
Age 60 or older, who have been members of the College for ten or more years and who are working 20 or fewer hours per week (or fully retired), are eligible for Emeritus membership status and a 50 percent reduction in membership dues. All three criteria must be met to be eligible for this discount.



Part Time (Temporary reduction only, renewable annually upon request)
Under age 60, early retirement, unemployed, or working 20 hours or less per week.



*Date:

 

Dues adjustments are generally temporary and renewable once, depending on the individualís circumstances, and do not affect membership status or benefits unless otherwise noted. You may be asked to provide additional information and/or documentation. Information provided will be considered confidential. Please allow up to four weeks for review and notification of decision.

Questions: 800-523-1546, extension 2600 or 215-351-2600

Current Members

Log in to My Membership to pay your dues, change your address, and search the Membership Directory.

ACP Fellowship (FACP)

Internists and subspecialists who have been recognized for personal integrity, superior competence, professional accomplishment, and demonstrated scholarship may be eligible to become an ACP Fellow.

Recruit-a-Colleague

Recommend ACP Membership to your colleagues and earn a significant discount on your membership dues or even free membership. Help strengthen the voice of internal medicine!