Registration Form July l, 2024 – June 30, 2025 Membership Application Mission:The Rochester Regional Health Information Management Association promotes professional excellence and provides growth opportunities for its members and the region. Please complete the following form. Name* First Last AHIMA NumberPick a Username*Pick a Password* Enter Password Confirm Password Credentials (Check all that apply):* None RHIA RHIT CCS CCS-P CPC CHC CDIP CHDA CTR CHPS Other Other Credentials*Employer*Job Title*Are you a student enrolled in an CAHIIM Accredited HIA/HIT, Masters or Coding Program?*YesNoWhich program and educational institution?*Name of Program*Applicant Graduation Date:* Date Format: MM slash DD slash YYYY Preferred Address:*HomeWorkAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* *(Please provide a personal email, if possible. Work emails sometimes have firewalls that block our emails from reaching members.) Are you a Dues Paying Member of:NYHIMA*YesNoAHIMA*YesNoAnother NYS CLA (local association)*YesNoIf yes, identify which CLA?*Which CLA is your primary CLA?RRHIMAOther CLAWhich position(s) do you currently hold, or have you held in the past for RRHIMA or another AHIMA State or local component association? (Click all that apply)* Select All President-Elect Past President President Project Manager Director of Communications Committee Chair Director of Finance Special Interest Group (SIG) Facilitator Director of Education NYHIMA Delegate or Committee Liaison Director of Membership Engagement Student Representative None at this time What BOD positions are you interested in? (Check all that apply)* Select All President Membership Engagement Communications Education Finance Student Rep None at this time Which committees or activities might you be interested helping with as a volunteer? (Check all that apply).* Select All Advocacy Annual Meeting Planning Team Archives Awards Committee Communications Education Committee Membership Committee Newsletter Public Relations Social/Service Events Speaker/Presenter Strategic Planning Website/Social Media Coder Special Interest Group LTC Special Interest Group Professional Development Special Interest Group None at this time Membership Category (Select the appropriate status.)*Dues PayingBoard MemberEmeritusSpecial StatusStudentSee Membership Categories page for category descriptions.Total $0.00 Select Payment Method*PaypalCheck or VoucherNone If paying by check, please mail your check payable to RRHIMA to the address listed below. In the check’s memo field please write “Member Name; RRHIMA Dues 2024-2025. Brandy Almekinder RRHIMA Director of Finance 3905 Middle Sodus Rd Lyons, NY 14489 For use by Membership/Database Project Manager:Specific methodRRHIMA BOARD MemberDate of payment* Date Format: MM slash DD slash YYYY Payment amount*Check Number*Total $0.00
