Bridges to Independent Practice

Bridges to Independent Practice

Physician Intake Form
PMAG is dedicated to the success of independent physicians in Hawaii. Please fill out the following information to let us know how we can best help you and your practice.
Physician Name*

First NameMiddle InitialLast NameCredentials
Physician Gender
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Are you able to receive text messages?

YesNo
Office Phone Number
Please enter a valid phone number.
Office Fax Number
Please enter a valid phone number.
Do you have a physical office location?*

YesNo
Primary Office Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Office Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PMAG Membership Status
Select your PMAG membership status:*

MemberNon-memberApplying for membershipIn ResidencyOther

What best describes your current situation?
I am a:*

New physician interested in opening a private practiceEmployed physician looking to transition to private practiceOut-of-state physician moving to HawaiiPhysician needing help with my existing private practicePhysician transitioning to part-time or retirement

What area(s) do you most need help with?

Credentialing/licensingFinancing/loan optionsHR and staffingLegalOffice location/leasingEquipment and suppliesMarketingIT infrastructureOther
Describe more here:
Should be Empty:

PMAG Membership Status