American Medical Billing Association

AMBA Registration Form



Please print and send with your payment to AMBA.

Be sure to include your email address clearly written so we can send your AMBA Password Information and Confirmation via email. Please do not email this application with credit card information, because it will not be secure!

___I paid online (Please fax, mail or email this registration form to AMBA for our records.)

___Individual Membership $99

___Business Membership (You may include up to 3 separate members) $199

___Add $79 for Each Additional Business Member Over 3


Order Total:$__________________


Payment Method: ___Credit Card ___Check ___Money Order ___Cashiers Check

Credit Card: ___Visa ___Master Card ___Discover ___American Express

Credit Card #:________________________________________________

Credit Card Expiration: M_______Y______Credit Card Security Code __________

Name On Credit Card (Please print clearly):_______________________________________________

Signature:______________________________________________________________________


Member #1

Name:__________________________________Email:______________________________________

Member #2

Name:_________________________________Email:_______________________________________

Member #3

Name:_________________________________Email:_______________________________________

Member #4

Name:__________________________________Email:______________________________________


Business Name:_____________________________________________________________________

 (Address & information must match credit card billing statement)

Address:___________________________________________________________________________

                     
City:___________________________________________State:____________Zip:________________

Phone #:____________________________________Fax #:___________________________________

Website Address:_____________________________________________________________________

Date Business Started:_______________________

___ I am new and don't have any clients yet
___ 1-5 clients
___ 6-10 clients
___ 11-25 clients
___ 26-50 clients
___ Over 50 clients

My billing specialty is:

I am interested in continuing education courses covering:

___ Coding
___ Billing
___ Practice Management
___ Medicare/Medicaid
___ Compliance
___ HIPAA
___ Fraud & Abuse
___ Ethics and Quality Assurance
___ Risk Management
___ State Statutes Pertaining to Billing
___ Paperless Office
___ Information Technology and EDI Transactions
___ Marketing and Prospecting
___ Selling to Doctors
___ Other:___________________________________________________________

How did you learn about AMBA?

Were you referred by another AMBA Member? Y N

Name of Member that referred you:

If not a member, were you referred by:

Our Website? Y N
____ Medical Billing 101
____ Member's Webpage
____ Email Group or Listserv - which one? ____________________________________
____ Yahoo
____ Google
____ Other _______________________________________
What software program do you use to bill with:

Business and Professional Affiliations:

Formal education, certifications held and or training:

Work related experience:

Community activities, clubs or other:

Additional Comments:

I am interested in volunteering for the following committee's or programs:
___ AMBA National Advisory Board
___ Local Chapter
___ Conduct and Ethics Committee
___ Compliance and Assurance Committee
___ Policy and Regulations Committee
___ Continuing Education &Certification Committee
___ Research and Development Committee
___ Mentor Program
___ Relief and Backup Forum Moderator

Send Membership Application and Payment to:

American Medical Billing Association
2465 E. Main
Davis, OK 73030
(580) 369-2700

Or, fax your application with credit card payment to (580) 369-2703.

Please do not email this application with credit card information, because it will not be secure!