Membership Application Application 2009-2010 July 1, 2009 - June 30, 2010 *Application Type: New Membership Renewal *Member Type: Active ($20) Senior 65+ ($0 - no charge) Honorary - with board approval only ($0 - no charge) Student ($0 - no charge) School Name: AHIMA ID: *First Name: *Last Name: Credentials: Title: Organization: *Preferred Address: Address (cont'd): *City: *State: Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International *Zip Code: *Phone Home Phone *E-mail: Fax: *Work Status Select One Full Time Part Time Currently Unemployed Retired *Work Setting Select One Consultant/Vendor Correctional Facility Data Collection Agency Education Home Health Care Hospital LTC Facility Medical Group Practice Mental Health Facility Rehab Facility State/Fed Agency Not Applicable Other: *Job Type Select One Cancer/Tumor/ Trauma Registrar Coder/Data Analyst Coding Supervisor/Manager Consultant HIM Director/Privacy Officer HIM Manager/Supervisor IT Manager/CIO Educator Reimbursement/ Billing Specialist Student Transcription Manager/Supervisor Vendor Other I hereby request consideration for membership/renewal in the Southeastern Pennsylvania Health Information Management Association. Acceptance of Terms and Conditions I have reviewed and acknowledge acceptance of the terms and conditions which includes the refund policy, insufficient check funds policy, and the credit card terms and conditions. * Select One Yes, I agree to the terms and conditions Payment options include credit card and check (by mail).
Membership Application
Application 2009-2010 July 1, 2009 - June 30, 2010
*Application Type:
New Membership Renewal
*Member Type:
Active ($20) Senior 65+ ($0 - no charge) Honorary - with board approval only ($0 - no charge) Student ($0 - no charge) School Name:
AHIMA ID:
*First Name:
*Last Name:
Credentials:
Title:
Organization:
*Preferred Address:
Address (cont'd):
*City:
*State:
Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International
*Zip Code:
*Phone
Home Phone
*E-mail:
Fax:
Select One Full Time Part Time Currently Unemployed Retired
Select One Consultant/Vendor Correctional Facility Data Collection Agency Education Home Health Care Hospital LTC Facility Medical Group Practice Mental Health Facility Rehab Facility State/Fed Agency Not Applicable Other:
*Job Type
Select One Cancer/Tumor/ Trauma Registrar Coder/Data Analyst Coding Supervisor/Manager Consultant HIM Director/Privacy Officer HIM Manager/Supervisor IT Manager/CIO Educator Reimbursement/ Billing Specialist Student Transcription Manager/Supervisor Vendor Other
I hereby request consideration for membership/renewal in the Southeastern Pennsylvania Health Information Management Association.
I have reviewed and acknowledge acceptance of the terms and conditions which includes the refund policy, insufficient check funds policy, and the credit card terms and conditions.
* Select One Yes, I agree to the terms and conditions
Payment options include credit card and check (by mail).
Contact Webmaster
All web content © Copyright 2009 SePHIMA. All rights reserved.
