Nurse Practitioner Membership Application | Refractive Surgery Alliance Society

NP Membership Application - Tell us about yourself... (S)

Members in the Refractive Surgery Alliance Society are uniquely qualified to provide leadership in field of vision correction procedures and refractive surgery through education, research, management, patient care and other activities. Nurse Practitioners who are employed by an RSA Member Surgeon and who share these core values are welcome to apply for membership in the Refractive Surgery Alliance Society.

All Refractive Surgery Alliance Society Members pay Annual Dues. Dues are not prorated, however, dues for new members who join after July 1 of each year shall apply through the following year.

Refractive Surgery Alliance Society Annual Member Dues are as follows:
NP Working Full-Time for Charitable Organizations:
......Philanthropic: $100 / Year
Military Service Member NP:
......Active Duty Military: $100 / Year
Practicing NP:
......1st year in practice: $100 / Year
......2nd year in practice: $200 / Year
......3rd year in practice: $300 / Year
......4th year in practice: $400 / Year
......5th year or more in practice: $500 / Year

Emeritus NP:
......Emeritus NP: $300 / Year

......“First Collaborative Care Member (inclusive of OD’s, NP’s, RN’s, and/or PA’s) - $500.”
......“Each Additional Collaborative Care Member (inclusive of OD’s, NP’s, RN’s, and/or PA’s) - $250.”
Collaborative Care Members in Practice - Are you the First Collaborative Care Member Making Application?
Example:
……….One (1) Collaborative Care Member - $500
……….Two (2) Collaborative Care Members - $750 ($250 each Additional CC Member)
……….Three (3) Collaborative Care Members - $1,000 ($250 each Additional CC Member)
……….Four (4) Collaborative Care Members - $1,250 ($250 each Additional CC Member)
……….Etc…
Annual Member Dues (Select One)*
Payment of the Annual Member Dues is required prior to review of Membership Application. In the unlikely event, your Membership Application is declined, the Annual Member Dues submitted with your application will be refunded (via check in USD) to the address provided in your application less a handling fee of $50.00 USD.
Annual Member Dues - Additional NP (Select One)*
Payment of the Annual Member Dues is required prior to review of Membership Application. In the unlikely event, your Membership Application is declined, the Annual Member Dues submitted with your application will be refunded (via check in USD) to the address provided in your application less a handling fee of $50.00 USD.
Name*
Include any titles (Jr. or Sr. or IV) in the "Suffix" field. Your medical "Credentials" will be added in the "Credentials" field which follows this one.
First Last Suffix (Sr, Jr, IV, etc)
Credentials (NP)*
Please include here the Credentials which will follow your name on your Member Page. (i.e. NP, etc...)
Board Certification*
- Board-Certified
- Board-Eligible
- Neither
- Other
Certifying Board*

Please provide the name of the board which awarded your certification(s). i.e. AANP for American Academy of Nurse Practitioners, etc... Enter "Board-Eligible" if you have not yet taken your boards or enter the certifying body from whom you are certified/eligible to be certified.
Year of Board Certification*

If you are "Board Eligible", simply include the year you anticipate taking your boards. If you selected "Neither" or "Other" enter N/A.
Email*
Enter Email Confirm Email
Practice Name*
Practice Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Practice Phone*
Practice Website*
Name of the RSA Surgeon Sponsoring Your Application*
Include any titles (Jr. or Sr. or IV) in the "Last" field. Enter the medical "Credentials" the "Credentials" field which follows this one.
First Last MD, DO, MBBS, etc)
Practice Name of the Sponsoring RSA Surgeon*
What year did you begin practicing as an NP?*
Tell us about yourself...*
Please describe your practice and your interest in the Refractive Surgery Alliance Society.
Have you ever lost professional privileges due to disciplinary action? If so, please explain:*
- Yes
- No
Briefly explain when and why loss of privileges occurred.*
Have you ever lost a malpractice judgement and/or paid a settlement to avoid a malpractice judgement? If so, please explain:*
- Yes
- No
Briefly explain when judgement/settlement occurred and what happenned.*
Are there any outstanding complaints against you in a state licensing board, hospital and/or professional association? If so, please explain:*
- Yes
- No
Briefly explain with whom any outstanding complaint exists and generally what it is about.*
Have you ever been convicted of a felony? If yes, please explain:*
- Yes
- No
Briefly explain felony conviction.*
Home Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Biography (Not your CV)*
Members receive a "Member Bio Page" on the Refractive Surgery Alliance website, among other things. Please provide a short biography about yourself to be included on your RSA Member Page upon approval of your application for membership. This will serve as an introduction to web site visitors. Please use "third person" in writing style. (i.e. Mary Jones, NP is the Managing Director of World Pharmaceuticals headquartered in Bern Switzerland. Ms. Jones is a graduate of...)

This page provides potential patients with an insight into your personal approach to refractive surgery. It should reflect your passion, your philosophy and your purpose. It should NOT repeat what is published on your practice web page, but should speak directly to patients as if they met you in your office. Sterile content about your professional background is not as compelling as statements about your commitment to helping them achieve their goals in pursuit of better vision.

The following general format may be appropriate – this is your page so make it what you want it to be:
- Paragraph 1: Who you are, where you serve, why you practice.
- Paragraph 2: What a patient can expect from the professional services you provide.
- Paragraph 3: What motivates you to practice in the field of vision correction services for refractive surgery?
- Paragraph 4: Credentials/Training/Positions/Accolades/Areas of Professional Expertise and Interest.
- Paragraph 5: Any personal information you may want to divulge (family, hobbies, charity work, etc.)
Maximum character count 3000.
Photo*
Please upload a color portrait of yourself. Please choose a current, high quality, high resolution image. Professionally produced is preferred but not required. You may upload up to three portraits. We will crop image to size needed so 1500x1500 image is not too large.
Drop files here or

Accepted file types: jpg, gif, png, Max. file size: 2 MB, Max. files: 3.
Additional Comments (Optional)
Please provide any other information you would like considered with this RSA Membership Application.
By checking below, I acknowledge that I have read and agree to be bound by Refractive Surgery Alliance Society Conditions of Participation and the Refractive Surgery Alliance Society By Laws provided below:*
Refractive Surgery Alliance Society Conditions of Participation (Click to Download);
b) The Refractive Surgery Alliance Society By Laws (Click to Download)
- I acknowledge and agree to be bound by the RSA Conditions of Participation and the RSA By Laws provided herein. I further understand and commit to collaborate with Refractive Surgery Alliance Society colleagues to grow refractive surgery, particularly colleagues in my market.
Billing Address*
Same as Practice Address

Street Address City State / Province / Region ZIP / Postal Code Country
Total Annual Membership
$0.00
Credit Card*
Card Details
Cardholder Name

The Refractive Surgery Alliance is a professional organization and does not provide medical services or advice. Information provided here is obtained from a variety of sources and is provided for informational services, only.

NP Membership Application - Tell us about yourself... (S)