Regional Association Membership Application - MVHIMA
Please complete the application below. Prior to submiting, please print a copy and send with the appropriate check or money order (payable to "MVHIMA")via U.S. Mail to: Tina Whytal, 7052 Emerald Ave, Enon, Oh 45323.
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Response Required
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1. First Name:
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2. Last Name:
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3. Credentials (Check all that apply)
RHIA
RHIT
CCS
CCS-P
Other
Non-credentialed/Student
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4. Mailing Preference:
Email
Paper
5. AHIMA ID#:
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6. Street Address (home):
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7. City (home):
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8. State (home):
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9. Zip Code (home):
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10. Home Phone
11. E-Mail Address (home):
12. Employer:
13. Street Address (work):
14. City (work):
15. State (work):
16. Zip Code (work):
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17. Email Address (work):
18. Job Title (i.e. Coder, Transcription):
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19. Membership Category:
Active- Credentialed/Non-Credentialed (Dues $10.00/year)
Student- Degree Seeking Health Information Management(who does not have a previous degree from an HIM program of study(Dues waived by Association)
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20. Membership Type:
New
Renewal
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21. I hereby apply for membership and agree to abide by the Bylaws of the Miami Valley Health Information Management Association.
Yes
No
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