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Full name
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Practice/Facility Name
*
Specialty
*
...
Ob-gyn
Gynecology-only
Ob-only
Other (select from below)
Subspecialty
...
Complex Family Planning
Critical Care Medicine
Female Pelvic Medicine & Reconstructive Surgery
Gynecologic Oncology
Hospice & Palliative Medicine
Maternal-Fetal Medicine
Reproductive Endocrinology & Infertility
Practice type (select most applicable)
*
...
Private Practice
Hospital
Teaching Hospital
Rural Qualified Health Center
VA/Military Facility
Birth Center (free-standing)
Indian Health Service
Correctional Facility
Other
Payers Accepted (enter other here)
Medicare
Medicare Advantage
Medicaid
Medicaid Managed Care
Tricare
Aetna/CVS
Anthem/BCBS
Cigna
Humana
UnitedHealthcare
Email
*
ACOG Member Status
*
...
Member - Physician
Staff of Member
Non-member - Physician
Non-member - Coder/Biller
Non-member - Industry
Member - Other
Non-member - Other
ACOG Member Name and/or Number (Enter N/A if non-member)
*
ACOG District
*
...
District I
District II
District III
District IV
District V
District VI
District VII
District VIII
District IX
AFD
District XI
District XII
N/A
Work phone
State or Territory
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CT
DE
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FL
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HI
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IL
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IA
KS
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ME
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MS
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NE
NV
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NJ
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NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
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VA
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WI
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APO/FPO/DPO
AS
FM
GU
MH
MP
PW
PR
VI
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