Diplomate Application
(to be completed only by Current Members)

You may print this form and fill it out offline or fill it out online, print it and FAX it to us at 562 799-3355 
or mail it to 1945 Palo Verde Ave. Suite 202, Long Beach, CA 90815-3445. 
If you prefer to complete the application process online, use the "Submit" button at the bottom of this page

Name   As you want it to appear on certificate
Title
Organization
Address
Suite or Apt.
City
State/Province
Zip code
Work Phone
FAX
E-mail Required for Internet membership
URL
Date of birth   Male  Female
Degree / Certification Profession
M.D.
D.O.
D.D.S., D.M.D.
Ph.D. 
Psy.D.
D.C.
O.D.
LCSW
MFT/MFCC
MA
RN 
CEAP
LVN
LPT
CNA 
CEO  		 Physician  --  Specialty
Psychologist
Dentist
Chiropractor
Optometrist
Social Worker
Marriage/Family Therapist
Nurse
Employee Assistance Professional
Chemical Dependency Counselor
MCO Management Staff
MCO Case Manager
MCO Professional Staff
Other Healthcare Provider
Allied Professional 
Other Non-licensed Professional 

 

Education
Undergraduate School Degree Date
Graduate School   Degree Date
Medical/Professional School Degree Date
Internship/Residency Location & Dates
Professional Association Memberships
Managed Care, PPO, IPA HMO Memberships & Contracts
Professional References (Name, Address)
Managed Care Organization References (Name, Position, Company)
Additional information:
All of the items below must be checked or an explanation must be given in the box below.
I currently possess a valid license to practice my profession
My license has never been suspended or revoked, nor am I presently under investigation 
I have never been removed or suspended from a managed care organization provider panel
I have never been convicted of a felony
I have never been disciplined by any national, state or local professional association
Please provide a written explanation of any unchecked boxes below:


By submitting this form on-line, I attest that all of the information in this application is accurate and truthful.  I understand that willful falsification or failure to disclose pertinent information constitutes grounds for denial or subsequent forfeiture of membership and/or Diplomate status.  Submission of this form authorizes the Academy of Managed Care Providers to verify information provided herein.

Please provide the following billing information:

Credit card

Amount Authorized
Cardholder name
Card number
Expiration date