Application for Membership

I hereby make application for membership in the Community Bridges Integrated Healthcare IPA. I understand that by doing so that I will receive all benefits and referrals in my geographic area from patients that select me,

Community Bridges Integrated Healthcare strives to:

Bring cooperation between complimentary providers and allopathic providers.

Support a holistic care concept for patients and their family

Assist to improve the well being of its members with referrals, educational programs, networking, and providing an avenue for exchange of ideas.

Provide an Annual Educational forum for Health Fitness and Wellness to come together for common good.

All CBI-IPA members receive the Quarterly CBI-IPA Members Only Newsletter for member networking and sharing association news. In addition, a number of member companies offer discounts to CBI-IPA members.

The special membership options (Practitioner, Organizational, and Institutional) offer a number of valuable extra member benefits, including quality networking exposure and a certificate suitable for framing.

Provider Membership Options

CBI-IPA General Membership is $25, and open to any individual or organization.

CBI-IPA Practitioner Membership is $50, and open to healthcare practitioners of any established modality, which delivers care with the holistic philosophy.

CBI-IPA Organizational Membership is $100, and open to companies/ organizations offering health-related products, services, and educational opportunities.

CBI-IPA Institutional Membership is $100, and open to healing centers in North American that integrate conventional medicine and alternative therapies or exclusively offer alternative therapies.

Community Bridges IPA

Application

Name______________________________________________________________________

Office or Practice Name________________________________________________________

Address_____________________________________________________________________

City________________________________ State__________ Zip Code________________

E-mail______________________________________________________________________

Telephone_____________________________________ Fax__________________________

Practioner Information _____M.D ____D.O.____N.D._____P.A.____R.N. ____N.P.______Chiropractor ______

Podiatrist _____Massage Therapist_____Physicial Therapist _______Other please list

___________________________________________________________________________

Annual Membership & Certificate: Payable to Community Bridges Integrated Healthcare P.O. Box 112, Caro, Michigan 48723

General Membership $25___ Practitioner Membership$50___

Organizational Membership $100___ Institutional Membership $100___

Discount I agree to give to referred member patients 5%___ 10%___ Other list____%

on what services_______all

Limited to list____________________________________________________________

Visa___ MasterCard___ American Express__ Amount of Charge__________

Name_________________________________________

Billing Adress____________________________________________________________

City_________________ State___________ Zip Code____________________________

Card Number___________________________________ four digit code________

Expires_____________________

Signature________________________________________________

Fax to: 989-672-2483