SPAHQ Member Registration Form

SOUTHEASTERN PENNSYLVANIA ASSOCIATION FOR HEALTHCARE QUALITY

2009 APPLICATION FOR MEMBERSHIP
* Type of Membership (01/01/09 through 12/31/09)
Corporate - $125.00* Individual - $35.00 (FREE to Fall Conference Attendees)
* New Membership or Renewal
New Renewal
Corporate membership allows up to six people to register for SPAHQ educational programs/seminars at the membership rate. There are no voting privileges for Corporate Membership. SPAHQ mailings will be sent to one Corporate Contact Person named below.
* Organization Name
* Your Name (or Corporate Contact Person) First Name Last Title
* Address

Street Address

Unit# / Apt# / P.O.Box

City

State Zip Code
Preferred Mailing Address( if different than above)

Street Address

Unit# / Apt# / P.O.Box

City

State Zip Code
* Email Phone - Area - ### #### Fax - Area - ### ####

Organization/Facility Type:

Area(s) of Responsibility/Specialization/Interest:

Performance/Quality Improvement	Risk Management
Utilization Management	Contract Management
Case Management	Regulatory/Compliance (TJC, CMS, etc.)

Check if interested in serving on any of the following SPAHQ Committees:

* Please Select Method of Payment:
Send Check by Mail Secure Online Payment by Credit Card
- Please make sure that all questions printed in red have been answered.
- Then, click CONTINUE to print and submit your application.

Acute Care Community Hospital	Psychiatric Facility	Health System (corporate)
Teaching/University Hospital	Rehabilitation Facility	Home Health Care
Federal/VA Hospital	Long Term Care	Managed Care Company
Healthcare consulting	Other