Regional Association Membership Application - EOHIMA
Please complete the application below and submit with the appropriate check or money order (payable to "EOHIMA")via U.S. Mail to: Nancy Wilkinson 1010 Essex Ln Medina, OH 44256-3827
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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
CCA
CCS
CCS-P
CHP
CHS
CHPS
Student
Other
4. AHIMA ID#
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5. Daytime Phone
6. Evening Phone
7. Work Phone
8. Fax Number
**Extremely Important** To reduce expenses, meeting notices will be sent via e-mail ONLY to those with valid e-mail addresses. Please notify EOHIMA by updating your membership form online at www.ohima.org.
9. E-Mail Address
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10. Street Address
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11. City
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12. State
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13. Zip Code (please use +4 if known)
14. Facility Name
15. Type
16. Position Title
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17. 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.
18. 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
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19. Membership Class
Active = $15 (Holds a valid AHIMA credential)
Student = FREE (approved HIA/HIT/Coding program)
Commercial = $30
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20. Are you interested in serving on the EOHIMA Board?
Yes
No
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21. Are you interested in serving on a Committee?
Yes
No
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22. May we publish your contact information & position on a roster available to the members for networking opportunities?
Yes
No
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