Confidential Request for Dues Adjustment

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Please remember to print a copy of this form for your records.
Address
State/Province
Please indicate the type of dues adjustment being requested:
Dues Adjustment Type:

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

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

I am under age 60, and have retired early, or are , unemployed, or working 20 hours or less per week.

You must provide additional information below.
Condition Type
Employment Type
You must provide additional information below.
Dues Type
You must provide additional information below.
Dues Type

Dues adjustments are generally temporary and renewable once, depending on the individual’s circumstances, and do not affect membership status or benefits unless otherwise noted. You may be asked to provide additional information and/or documentation. Information provided will be considered confidential. Please allow up to four weeks for review and notification of decision.

Questions: Contact us (M–F, 9 a.m.–5 p.m. ET) 800-ACP-1915 (800-227-1915), or direct at 215-351-2600.