PHIMA | Pennsylvania Health Information Management Association

About PHIMA – Premiere Membership Form
July 1, 2008-June 30, 2009

Demographic Information

*AHIMA ID:
*First Name:
*Last Name:
Credentials:
Title:
Organization:
*Preferred Address:
Address (cont'd):
*City:
*State:
*Zip Code:
*Home Phone:
Work Phone:	Ext.
Fax:
*E-mail:

Pennsylvania Regional Associations

*I am a member of one of the following regional association:

I would like to become a member of:

General Questions

Would you like to volunteer for one or more of the following PHIMA committee and/or task?

Education for the Association throughout the year
Arrangements for Annual Meeting
Advocacy - Release of Information, etc.
(Preparing the new manual)
Coding Roundtable
Public Relations - Articles and information for the
Keystoner
Technology - PHIMA Website
Pennsylvania eHealth Initiative

Other (please specify):

* Would you like your PHIMA member information published in our PHIMA Membership Directory?

Yes
No

* Do you wish to have your name provided for outside mailing lists (e.g. vendors, recruiters)?

Yes
No

Questions/Comments

Please enter any questions or comments that you may have for PHIMA.

I agree with the terms and conditions.

Membership

Local Associations

Leadership Staff Directory

Committee and Rosters

Distinguished Member Award

PHIMA Documents