Legislative Key Contact Registration Form

Physician leaders from CMS & CMA Registration form

CMA, the voice of California physicians, relies on the involvement of physicians like you to communicate the physician vision of medical care to lawmakers, and to the regulators who determine how medicine is practiced in California.

Personal contact with elected representatives makes a big difference — sometimes all the difference — in how votes are cast in Sacramento and in Washington. When you sign on as a legislative key contact, you will receive e-mailed “action alerts” from CMA when a key issue is breaking.

The alerts will provide background information and talking points, and will ask you to call, fax, or e-mail a letter to your representatives. Key contacts also make in-person visits to lawmakers to help educate them and guide their votes on critical bills.

To sign up, fill out the form below or download a PDF application to be submitted by mail or fax.

Your office address will be used for providing matching legislator information. The program now supports e-mail outreach only (we are no longer able to fax key contact alerts), so please provide an e-mail address that you check frequently.

Physician Name:	*
CMAID:	*
Office Address:	*
Office City:	*
Zip:	*
Office Phone:	*
Office Fax:	*
E-mail:	*
Specialty:	*
County Medical Society:	*
Political Party:

Type of Practice: *
Solo/Small Group (1 - 4) Drs.)
Medium ( 5 - 150 Drs.)
Large ( 150 - 1,000 Drs.)
Very Large (1,000+ Drs.)
Administrative
Retired
Academic/Faculty
Govt. Employed
Hospital Based
Name of Organization/Medical Group

Legislators You Know:
Please indicate legislators you know - even if they do not represent the district in which you practice or reside. See codes below for describing your relationship with the legislator.

Legislator Name:	Types of Relationship (Select all applicable)
	Constituent Neighbor Social acquaintance Friend Campaign contributor Attended a fundraiser Met at a meeting Campaign supporter Immediate access to legislator Other (please specify)

Legislator Name:	Types of Relationship (Select all applicable)
	Constituent Neighbor Social acquaintance Friend Campaign contributor Attended a fundraiser Met at a meeting Campaign supporter Immediate access to legislator Other (please specify)

Legislator Name:	Types of Relationship (Select all applicable)
	Constituent Neighbor Social acquaintance Friend Campaign contributor Attended a fundraiser Met at a meeting Campaign supporter Immediate access to legislator Other (please specify)
Comments:

SEE YOUR AD HERE