Regional Association Membership Application - NOHIMA
After completing and submitting this online form, forward a check made payable to NOHIMA to:
Kathy Loflin, RHIA
Health Information Management
Cuyahoga Community College, Metro Campus
2900 Community College Avenue
Health Careers & Science Bldg, 106-E
Cleveland, Ohio 44115-3196
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Response Required
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1. First Name
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2. Last Name
3. Credentials (check all that apply)
RHIA
RHIT
CCS
CCS-P
CCA
CHP
CHPS
NON-CREDENTIALED/STUDENT
OTHER
4. AHIMA ID#:
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5. Street Address
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6. City
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7. State
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8. Zip Code
9. E-Mail Address
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10. Home Phone
11. Employment Facility
Acute Care Hospital
Long-Term Care
Home Health
Physician Office
Ambulatory Care
Mental Health
Information Systems
Other (please specify)
12. Office Phone
13. Fax Number
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14. Position Code
01 Facility Administrator
02 Director, Health Info Services
03 Director, Not Health Info Services
04 Assistant Director, Health Info Services
05 Assistant Director, Not Health Info Services
06 Supervisor, Health Info Services
07 Supervisor, Not Health Info Services
08 Student, HIM Program
09 Non-Supervisor Tech or Department Other than Health Info Services
10 Director, HIM Ed Program
11 Faculty, HIM Ed Program
12 Consultant, self-employed
13 Consultant, Non self-employed
14 DRG Analyst
16 Salesperson
20 Coder
21 Abstractor
22 Transcriptionist
24 Analyst
25 Assembler
26 Re-Analyst
27 Correspondence
28 Stats Coordinator
29 Other (please specify)
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15. Membership Status
New Membership
Renewal
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16. Membership Type
Active ($15)
Student ($10)
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17. Date (00/00/00)
18. Comments
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