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

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

^*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

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