EMBC Membership Application

Thank you for your interest in joining EMBC as a member. Please complete the below application for your EM Group.
If you have any questions during the process please let us know (info@embusinesscoalition.org). If you have additional information you would like to share about your EM group, please email info@embusinesscoalition.org.

EMBC Guiding Principles:

EMBC members have a meaningful commitment to EM.
EMBC members are expected to support other member groups, although natural competition for contracts may continue to occur between member groups.
EMBC’s primary focus will be to pool any possible resources among member groups to support the currently contracted group in maintaining their contract.

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* 1. Contact / Practice Group Information

Name

Company/EM Group

I hereby confirm that the information shared in this application is correct to the best of my current knowledge.

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Knowing our members' employee count assists EMBC in working with our broker partner to establish the best terms and rates for EMBC’s collective purchasing programs. Please provide the number of full and part-time employees within your practice below. Do not include per diem employees.

EMBC Membership Criteria Questions

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* 3. Your EM group demonstrates a revenue of at least 50% from EM interests.

Yes

If you have answered “no”, please provide a further detailed response.

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* 4. Your EM group has a majority (>50%) of ownership from clinicians working or dedicated to the EM clinical enterprise.

Yes

If you have answered “no”, please provide a further detailed response.

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* 5. Your EM Group is >75% physician-owned and <25% non-physician owned, which may include other clinicians, administrators, and/or private equity.

Yes

If you have answered “no”, please provide a further detailed response.

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* 6. EM Group provides the opportunity for ownership (shares, units, or equivalent) to full-time physician employees.

Yes

If you have answered “no”, please provide a further detailed response.

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* 7. Does your EM group have flat ownership?

Yes

If you have answered “no”, please provide a further detailed response.

Governance may be run by shareholders directly, via a board of directors, or similar representative body.

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* 8. In the case of a shareholder direct governance, do all shareholders have less than 50% of the outstanding shares? (No single shareholder has greater than 50% of all outstanding shares.)

Yes

N/A

If you have answered “no” or "N/A", please provide a further detailed response.

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* 9. In the case of a board of directors (or representative body), the physician representation meets or exceeds two-thirds of voting authority in your EM Group.

Yes

N/A

If you have answered “no” or "N/A", please provide a further detailed response.

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* 10. Your EM Group compensation for physicians represents reasonable regional market compensation.

Yes

If you have answered “no”, please provide a further detailed response.

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* 11. Your EM Group’s total compensation for administrators does not exceed the compensation for equally qualified clinical full-time employees overall and on an hourly basis.

Yes

If you have answered “no”, please provide a further detailed response.

EMBC Membership Dues Structure

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* 12. EMBC membership dues is a base fee of $2,000 plus $0.05 per patient visit with a maximum of $10,000.

In this box, please share the number (in numeric value) of patient visits (including but not limited to in-person emergency room visits, in-person urgent care visits, and all telemedicine visits), in the past 12 months from the quarter prior to completing this form.

For example,

if you are completing this in Q2 of 2021, it would be Q2, Q3, and Q4 2020, and Q1 of 2021.

if you are completing this in Q3 of 2021, it would be Q3 and Q4 2020, and Q1 and Q2 of 2021.