Network Medical Directors Email Sign-Up Form

Thank you for your interest in joining our physician-to-physician email distribution. Emails from the Independence Network Medical Directors will provide direct, clear, and succinct messaging that will assist physicians in providing quality care to our members. Email topics may include policy and billing changes, important upcoming mailings, future fee schedule updates and more.

Please complete the information below and click Submit.

*Email address:
*First name:
*Last name:
  Phone number:
*Street address 1:
  Street address 2:
*State: *ZIP code:
  Job title:
  Medical degree:
*Participating with Independence?
*Your medical specialty:
To ensure your privacy, all information will be sent via a secure connection. Independence will not disclose any personal information to outside persons or entities unless we have written consent or unless authorized by law.

Please see our Notice of Privacy Practices for more information.