Regional Association Membership Application - NWOHIMA

Please complete the application below and click the submit button. Print copy of application prior to clicking the submit button to mail in with fee, if applicable. Make check or money order payable to "NWOHIMA" and mail to:

NWOHIMA
P.O. Box 235
Perrysburg, OH 43552-0235

Printable Membership Application


*First Name




*Last Name




*Credentials (Check all that apply)

 RHIA
 RHIT
 CCA
 CCS
 CCS-P
 CHP
 CHS
 CHPS
 Student
 Other


AHIMA ID#




*Daytime Phone




Evening Phone




Work Phone




Fax Number





**Extremely Important** To reduce expenses, meeting notices will be sent via e-mail ONLY to those with valid e-mail addresses. If your email address should change, please update your information on the AHIMA website. NWOHIMA does not share or sell its membership information.

*E-Mail Address




*Street Address




*City




*State




*Zip Code (please use +4 if known)




Facility Name




Position Title




Department





Please select the areas below that describe your present position or interest so that we can best meet the educational needs of our members.

Type of Facility (check all that apply)

 Administrator/Director/Manager/Supervisor
 Business Owner
 Medico-legal Correspondence
 Sales Representative
 Coder/Abstractor/Auditor-Type (inpt/outpt/E&M) (Please specify below)
 Statistical Coordinator
 Consultant- Type_______(Please specify below)
 Student
 Information Systems/EHR
 Transcriptionist
 Instructor/Faculty of HIM-related programs
 Tumor Registrar
 Other (please specify below)
 Additional information


*Membership Class

 Active = $15 (Individual who holds a valid AHIMA credential or is a Non-credentialed interested in HIM)
 Student = FREE (Enrolled in an AHIMA accredited HIA/HIT/Coding program). Please indicate college attending.


*Are you interested in serving on the NWOHIMA Board?

 Yes
 No


*Are you interested in serving on a Committee?

 Yes
 No


*May we publish your contact information & position on a roster available to the members for networking opportunities?

 Yes
 No

   

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****In order to confirm membership, a receipt will be emailed once payment is received. A membership card will then be mailed****