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Supporter Application Form For DSC Alliance
This information will be used to build internal and public directories of DSC Alliance members. Your information will NEVER be shared or sold to third-parties. If you have any questions, please feel free to contact us to discuss.

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Are you a specialist physician practicing or interested in direct care model? *
First and Last Name  (as displayed professionally) *
National Provider Identification Number *
Medical School Graduate *
Medical Degree (MD/DO/DPM) *
Year of Graduation *
Residency Training Program *
Fellowship Program/ specialty *
Name and address of your current practice *
Contact information for your practice (Office #, Fax #, Website) *
What is your preferred email? This will be stored in the directory, not listed on the website. You will receive important announcements from the DSC Alliance and will not be shared with third parties without your agreement.   *
What is the best way to get in contact with you? Email/ phone/ text message?
The year of starting/planning to start your DSC practice?
Do you agree to have your practice listed on the DSC Alliance website? *
The supporter contribution will be soon determined. Benefits are:  access to educational materials, networking,  online meetings, your practice will be listed on the DSC alliance website. Many other benefits will come as the alliance grows. Once your application is reviewed, you will be informed if the application is approved. *
Your signature *
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