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Member Registration
ABOUT PHYSICIANS’ RESEARCH NETWORK

PRN’s mission is to provide ongoing peer support to physicians, nurse practitioners and physician assistants providing care to people with, and at risk for, HIV disease and/or viral hepatitis. PRN is committed to improving the diagnosis, management and prevention of these epidemic viral diseases and their complications, and to enhancing the broad spectrum of skills utilized by our members.

Membership is limited to licensed physicians, nurse practitioners or physician assistants (MD, DO, NP and PAs) who provide care to patients with or at risk for HIV/AIDS.

PLEASE NOTE: ALL MEMBER INFORMATION IS KEPT CONFIDENTIAL.

Please fully complete application:
* Username
Usernames must be at least characters long
* Password
Passwords must be at least characters long
* Confirm Password
* Screen Name
If you leave this field blank, your screen name will be the same as your username
* Email Address
* Membership Type
* First Name
* Last Name
* Mailing Address
Additional Address Line
* City
* State
* ZIP Code
* Telephone (Voice)
Please include your extension if applicable.
* Degree
(membership is limited to these degrees)
Other Degree
* Medical License #
* State of Licensure
* Board Certified?
* Specialty
Other Specialty
* Are you credentialed in HIV medicine by AAHIVM?
* Are you a member of HIVMA or IDSA?
* Type of Practice
Other Type of Practice
* Location of Primary Medical Practice by ZIP Code
* Employer
(name of individual, hospital, university or organization employed by, if applicable)
* In what position?
Other Position
* Hospital Affiliation(s)
Academic Appointment(s)
(name of teaching institution, if applicable)

* Submit the word you see below:


  My answers to the above questions are true and accurate to the best of my knowledge.

* Indicates required fields