Membership Application

Please complete the information below and click submit to apply for SOCCI membership.

Note: The information entered into this form CANNOT be saved and completed at a later time. The form will need to be submitted at the time of data entry.

* indicates a required field.

Demographic Information
First Name:*
Middle Initial:
Last Name:*
Degree:*

Email Address:*
Office Phone:* (###-###-####)
Work Address (complete):
Academic Title (CSMC Professional Series):
Academic Title (non-CSMC Academic Institution):
Administrative Title:
Department:*

Membership Type*

Based on the Membership Policy, please select the type of membership for which you are applying:

Core Member
Collaborative Member
Associate Member

Documents

Please upload a statement* (maximum 1,500 words) which addresses:

your interest in joining the cancer center;
your cancer research focus or potential for collaborations with cancer center members

(maximum file size 6MB)

Please upload your current NIH biosketch* including completed sections A (Personal Statement), B (Positions and Honors), C (Selected Peer-reviewed Publications), and D (Research Support).
Sample biosketch is available at: http://grants.nih.gov/grants/funding/424/SF424R-R_biosketchsample_VerB.doc

(maximum file size 6MB)

Please upload a copy of your full Curriculum Vitae* in Cedars-Sinai standard format. Please highlight in yellow any publications that are cancer-related.

(maximum file size 6MB)

Cancer Research Areas of Interest

Please indicate up to three areas of cancer research interest.

Primary Interest:*
Other Interest:
Other Interest:

Membership Agreement and Submission*

Please indicate your agreement with the Membership Policy and your interest in joining the Cancer Center by reading the Membership Agreement and clicking on the submit button below:

CEDARS-SINAI MEDICAL CENTER
SAMUEL OSCHIN COMPREHENSIVE CANCER INSTITUTE
MEMBERSHIP AGREEMENT

1. Certifications. 
By my signature below I hereby certify that I meet the eligibility requirements for the membership status checked above (as set forth in the Samuel Oschin Comprehensive Cancer Institute Membership Criteria Policy (the "SOCCI Membership Policy")), that I will comply with all provisions of the SOCCI Membership Policy, including without limitation, those provisions related to membership responsibilities, resource access and assistance, application procedure, and membership review process, and that I agree to the terms and conditions set forth below.

2. Compliance.
a. Physician Members Only:  I certify that I am currently Board certified in my medical  specialty, and am a member in good standing of Cedars-Sinai Medical Center's ("Medical Center’s") Medical Staff with appropriate clinical privileges.  I will comply with all applicable provisions of the Constitution and Rules and Regulations of Medical Center’s Medical Staff.
b. All Members:  I will comply with California and federal law and all applicable policies and procedures of the Medical Center.

3. Conflict of Interest.
I agree to comply with Medical Center's Conflict of Interest Policy, and to electronically complete and execute on an annual basis the Medical Center’s Conflict of Interest questionnaire.

4. Independent Contractor.
No employer-employee relationship is created by this Agreement or by my membership in the SOCCI.  I am an independent contractor and as such shall have no claim under this Agreement or otherwise against Medical Center for vacation pay, sick leave, retirement benefits, social security, workers' compensation, disability, or unemployment insurance benefits, or employee benefits of any kind.  Medical Center shall neither have nor exercise any control or direction over the manner in which I provide professional services provided that such services shall be in accordance with current and generally accepted medical practices.

5. Billing.
Physician Members Only:  I will be solely responsible for billing and collecting for all physician services I provide to patients unless I have previously entered into a separate agreement with Medical Center with respect to billing and collection for my physician services.  All of my billing and collection activities shall be in compliance with applicable laws, customary professional practices, the Medicare and Medi-Cal programs, and other third-party payor programs, whether public or private.  Medical Center shall be solely responsible for billing and collecting all facility fees related to the operation of the SOCCI.  I will cooperate fully with Medical Center if any billing issues arise.

6. Term.
This Agreement has an initial term of one (1) year commencing on the date hereof, and shall expire after the initial one (1) year term unless extended by mutual written agreement of the parties.

7. Termination.
This Agreement may be terminated as follows:

a. Medical Center may terminate this Agreement on fifteen (15) days prior written notice to me if I am in material breach of the performance of my duties as set forth in this Agreement or my failure to fulfill any of my certifications herein.  

b. Medical Center may terminate this Agreement on fifteen (15) days prior written notice to me if I fails to comply with all provisions of the SOCCI Membership Policy. 

c. Either party may terminate this Agreement immediately upon written notice to the other party that the party providing notice has obtained advice from legal counsel that continuation of this Agreement could violate federal, state or local laws, regulations, or ordinances, or have a negative tax impact on Medical Center.

d. Physician Members Only:  Medical Center may terminate this Agreement immediately upon written notice to me in the event that I have failed to maintain Medical Staff membership in good standing with appropriate clinical privileges and without restrictions.  In such case, this Agreement terminates effective immediately upon delivery of such written notice.

8. Referral Laws.
Nothing in this Agreement is intended or shall require either party to violate the California or federal prohibitions on payments for referrals.  This Agreement does not create any obligation or requirement that I make referrals to Medical Center or that Medical Center refer patients to me.  Nothing in this Agreement is intended to limit or restrict me from establishing staff privileges at, referring any service to, or otherwise generating any business for any other person or entity.

9. General Provisions.
This Agreement sets forth the entire understanding of the parties and supersedes any and all prior oral or written understandings regarding the subject matter hereof.  This Agreement shall be governed by and construed in accordance with the laws of the State of California.  I may not assign my rights or delegate my duties under this Agreement without Medical Center's prior written approval.  In the event of any proceeding related to this Agreement, the losing party shall pay the prevailing party’s reasonable attorneys’ fees and expenses incurred in any phase of the dispute.

I have read the CSMC SOCCI Membership Agreement and AGREE to the terms and wish to submit my application to join SOCCI

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If you have problems submitting this form, please email:GroupSOCCImembership@cshs.org