Nurse Practitioner & Physician Assistant “Sponsored Affiliate Membership” Application to the Philadelphia Dermatological Society
As a Sponsored Affiliate Member, the following stipulations apply:
- There will be no voting or Committee privileges attached to this membership.
- The applicant must have an active, onsite collaborative MD/DO Supervisor/Sponsor and cannot be in private practice for themselves.
- The applicant must be sponsored by a dues-paying Philly Derm MD/DO member who will submit a letter of support for membership and will attest that they are directly supervising the NP/PA.
- The Executive Committee will review the application and vote on admission.
- Membership will be renewed annually and dues will be at the same level as Philly Derm MD/DO members.
- If the relationship is severed with MD/DO Sponsor, then the Sponsored Affiliate Membership terminates. You will need to identify a new Sponsor immediately and reapply.
This form must be completed by the Dermatologist in your Practice or Institution who is sponsoring your application. As noted above, this individual must be a Philly Derm member in good standing and is your acting collaborative supervisor. NPs and PAs in private practice for themselves are not eligible for membership.
In addition to your Resume and State License, a letter from your Sponsor attesting that they are directly supervising you must be uploaded with this application.
Your application must be renewed annually. Annual dues are currently $150/year.