Application for membership or renewal - Step one

 

You have two methods of submitting your membership application:

1. Print an application page from this website, fill it out, attach a check, and mail it in.
2. Fill out the online application on this website, pay using a credit card thru PayPal.

Apply using paper application and a check (This form can be used for new or renewal)

Apply online using PayPal for a credit card

 

 

Online Application

Field names in red are required fields. 

Year for which you are applying or renewing	2011 2012 2013 2014 2015	The membership year is from January 1 to December 31. There is no pro-ration of dues for part year.
New or Renewal?	New         Renewal
Status	Active        Lifetime	Active:  Those members involved in the improvement of health care quality and/or utilization management. Lifetime:  Those members approved by the Board of Directors as having rendered outstanding service to MAHQ.
NAHQ Membership #		If not an NAHQ (National) member, skip.
NAHQ Member Type	N/A     Individual      Group	If not an NAHQ (National) member, skip.
First Name, Middle Init.
Last Name
Credentials		List up to six (e.g. RN, BSN, MSW, PhD, etc.)
Job Title
Certification(s)		List up to six (e.g. ABQUAR, CPHQ, CCM, ACHE, etc.)
Mail Address
Mail City
Mail State
Mail Zip Code
Work/Affiliate Name
Work Address		Specify if different than above.
Work City		Specify if different than above.
Work State		Specify if different than above.
Work Zip		Specify if different than above.
Work Website		Specify the website address for your company or organization.
Phone (include area code and extension)
Fax (include area code and extension)
E-mail Address
Major Area of Work Specialty	1 2 3 4 5 6   Statistical Analysis 1 2 3 4 5 6   Quality Management 1 2 3 4 5 6   Discharge Planning 1 2 3 4 5 6   Administration 1 2 3 4 5 6   Information Systems 1 2 3 4 5 6   Medicine (Physician) 1 2 3 4 5 6   Consulting 1 2 3 4 5 6   Managed Care 1 2 3 4 5 6   Risk Management 1 2 3 4 5 6   Education 1 2 3 4 5 6   Medical Records 1 2 3 4 5 6   Utilization Management 1 2 3 4 5 6   Infection Control 1 2 3 4 5 6   Case Management 1 2 3 4 5 6   Social Work 1 2 3 4 5 6   Other	From the list of specialties at the left, please choose at least 1 but not more than 6 areas where you have competence in that specialty. Rank each of your choices from "1" to "6" where "1" is the highest competence and "6" is the lowest competence. PLEASE USE EACH NUMBER ONLY ONCE.
Currently employed?	YES         NO
Do you wish to receive mail from other groups?	YES        NO
Are you willing to participate on a committee or board?	YES        NO
Referred by?

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Revised: 01/20/12

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