2011-2012 Membership Application
The Executive Board of HAHIMA welcomes you to the 2011-2012 yearly association membership.
It is a pleasure to serve the Health Information Professionals of Houston and surrounding areas.         
 Thank you for your interest and support.
PREFERRED CONTACT INFORMATION
Name:
Address:
Zip:
State:
City:
Phone:
Alternate Phone #:
E-mail Address:
Job Title:
Employer:
I DO NOT WANT MY NAME/ADDRESS PUBLISHED IN THE MEMBERSHIP DIRECTORY:
PLEASE SEND MEMBERSHIP DIRECTORY TO ME ON CD.
TYPE OF MEMBERSHIP
Active: (Active Members must also be an active member of AHIMA) AHIMA#:
Check all that apply:
RHIA
 RHIT
 CCS
CCS-P
 CHS
CCA
CHPS
CHP
 Other
$40.00 ($50.00 October 1st)
Associate*: Other professional not an active member of AHIMA
$40.00 ($50.00 October 1st)
Student*: School/Program:
$15
Corporate: Name of Company
Company website address:
$300.00
Payment is due September 30th.  Fees increase after October 1st.
Annual membership payment includes membership through August, 2011
*Please note that Associate and Student members do not have voting privileges,                 
and may not hold office.
For Credit or Debit Card payment, return to Membership page at http://www.hahima.org