MHIMA | Missouri Health Information Management Association

*Required information

Demographic Information

*First Name
*Last Name
Credentials
Home
Address
City
State
Zip Code
*Home Telephone Number
Work
Place of Employment
Department
Address
City
State
Zip Code
Work Telephone Number
Email Address

* Correspondence Preference

Email will be the primary mode of meeting notification. In the event that mail cannot be sent electronically, choose a postal back up site in addition.

Please mail my correspondence to:

Home Office

* Membership Status (please check one)

	Active Member ($20.00)
	Retired Member (free)
	Student Member (free) School: Program:

Employment

Your place of primary employment is classified as: (check one)

	Acute care hospital
	Physician office
	Psychiatric care
	Consulting firm
	College/University
	Vendor
	Nursing home/Long term care/Rehab
	Ambulatory care (other than physician office)
	Insurance company/HMO/PPO
	Corporate office
	QIO/Government agency
	Other (specify)

Position Function

Your position is classified as: (select one)

	Health care facility administration
	Director, HIM Dept.
	Director, Dept. other than HIM
	Supervisor/Manager, HIM
	Supervisor/Manager, other than HIM
	Non-supervisory, HIM
	Non-supervisory other than HIM
	Director, HIA/HIT program
	Faculty, HIA/HIT program
	Consultant, self employed
	Consultant, employed by firm
	Other management (specify)
	Other non-management (specify)

Areas of Involvement

Check all areas that you are involved with in your employment.

	Transcription
	ICD-9-CM Coding
	Other Coding Systems (specify)
	Quality Improvement
	CPT/HCPCS Coding
	Statistics
	Case Management
	Release of Information
	Compliance/Audits
	Tumor Registry
	Trauma Registry
	Other Registries (specify)
	File Maintenance/Scanning
	Abstracting/Research
	Physician Relations
	Billing
	Data Management
	Cancer Registry
	Physician Relations
	Revenue Integrity
	MPI Maintenance
	Other (specify)

* Release of Information

From time to time, the Association receives requests from members, employers and others for a listing of members or a sub-group of members. The purpose of these requests includes job recruitment, networking opportunities, notice of educational programs (other than EMHIMA meetings), membership directory, etc. Do you give your permission for the Board to release your name and postal mailing address in response to such requests?

Yes

* Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the insufficient check funds policy and the credit card terms and conditions.

If you would like a copy of this completed membership form, please print a copy before you select "continue".