Representative certification form 2026

1. Click ‘Get Form’ to open the representative certification form in the editor.
2. In Part 1, enter the physician representative's name, title, email address, and preferred phone number. If you know the Medical Education (ME) number, include it; otherwise, leave it blank.
3. Indicate whether the physician representative is an AMA member and if they are a member of the AMA House of Delegates by selecting 'Yes' or 'No'.
4. Fill in your health care organization's name and the number of physicians within it. Provide details for the lead physician executive if different from the representative.
5. Complete your organization’s mailing address and any preferred mailing address for the physician representative.
6. In Part 2, check all applicable characteristics that describe your organization. Ensure that associate member organizations meet all required criteria.
7. In Part 3, certify that the information provided is accurate by checking the box and typing your name as an electronic signature.

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