I hereby apply for Membership in Doctors Manitoba. I agree to be governed by the By-laws of Doctors Manitoba. I understand how dues/​fees are assessed and paid.

Consent & Authorization for Collection, Use and Disclosure of Personal Information

I understand that ​“personal information” includes, but is not limited to, my name, addresses, date/​location of birth, gender, other demographic information, bloc of practice, specialty, billing number(s), Medical Identification Number of Canada (MINC), all contractual terms with, and financial compensation from, the Province of Manitoba (Manitoba Health and any other Department/​Agency), University of Manitoba, any Regional Health Authority, Workers Compensation Board, Manitoba Public Insurance and any other employer or contractor including fee-for-service payments, practice/​billing profiles, salary and/​or contract payments, other compensation and benefits, including sessional, administrative and/​or on-call payments/​stipends.

I authorize Doctors Manitoba to access, collect, use and disclose my personal information for the following limited purposes:

• To determine and maintain my membership status and personal and professional contact information in its databases.
• To obtain my Medical Identification Number of Canada (MINC) from the Federation of Medical Regulatory Authorities of Canada and the Medical Council of Canada.
• To determine my eligibility for, and communicate with me (by mail, phone or electronically) about, compensation and Doctors Manitoba benefit programs, products and services including the Professional Liability Insurance Fund (CMPA Rebate Program), Physician Retention Fund, Continuing Medical Education Fund, Maternity/​Parental Benefits Program, Mentorship Program, New Car Program, insurance and other benefit or affinity programs.
• To develop and market Doctors Manitoba benefit programs, products and services tailored to the interests of physicians, residents, medical students and other eligible purchasers (e.g. family members).
• To represent me and my professional interests, financial and otherwise, through advocacy, negotiation and arbitration.
• To represent the professional interests of physicians, financial and otherwise, through advocacy, negotiation and arbitration.
• To communicate with me (by mail, email, text message, fax or phone) about advocacy, negotiations and arbitration.

I authorize Doctors Manitoba to negotiate on my behalf with my employer, contractor(s) or the Province of Manitoba. I understand that this authorization will continue in full force until revoked by me in writing.