Confidential Request for Dues Adjustment

Disability (Permanent/temporary adjustment)

I have a medical condition that seriously interferes with the ability to practice medicine and/or earn income.

Financial Hardship (Temporary adjustment, with publications)

I am experiencing a sudden, unforeseen short-term financial difficulty resulting in substantial reduction of income.

RETIREE/SEMI-RETIRED – All criteria must be met to be eligible (a permanent adjustment; annual request for adjustment not required, adjustment will remain in place following approval unless membership lapses)

Please select the category of financial hardship for which you are applying.

Natural disaster impacting home or practice (for example, tornado, fire, hurricane)

Unexpected closure of practice

I understand that if granted a financial hardship dues adjustment, I cannot apply for a financial hardship dues adjustment again for a minimum of 10 years.

You must provide additional information below.

Permanent condition

Temporary condition

Medical condition

Impact on employment

Anticipated date of return to employment

Full time

Part time

Physician’s Note

One file only.
100 MB limit.
Allowed types: jpg, jpeg, pdf, doc, docx.

You must provide additional information below.

Please describe the circumstances for requesting this adjustment and how long and to what degree this will affect your ability to pay dues

You must provide additional information below.

I am age 72 or older, have been a member of the College for at least 20 years, have been a member in good standing for a minimum of 10 years, and am working fewer than 20 paid hours per week or am fully retired.

I am age 75 or older, have been a member of the College in good standing for at least 20 years, and am working fewer than 20 paid hours per week or am fully retired.