Pay Your Fees for Medical Staff Membership Online Physician Information (required fields are indicated with *) Full Name (e.g. Dr. John M. Smith) Order Full Name (e.g. Dr. John M. Smith) (value 1) Weight for row 1 0 Please enter the full name(s) for whom payment is being provided If you are paying for multiple people, please choose "Make a Custom Payment" from the payment options below. Email (For receipt purposes) Phone Fax Payment Type Select from Standard Fees/Dues Make a Custom Payment Specify Purpose Dollar Amount $ Select payment to make Initial application fee (physicians, dentists, podiatrists) - $300.00Initial application fee (allied health) - $150.00Medical staff dues (physicians, dentists, podiatrists) - $400.00Medical staff dues (allied health) - $150.00IRB Study fee (initial) - $2000.00IRB Study fee (renewal) - $250.00 Payment method Name on Credit Card First Name Last Name Credit Card Number Your 16 digits credit card number. Expiration Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Expiration Year 20192020202120222023202420252026202720282029 CVV Code Your 3 or 4 digit security code on the back of your card. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.