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
___ More than 10 clients

My billing specialty is:

I am interested in continuing education courses covering:

___ Coding
___ Marketing and Prospecting
___ Compliance
___ Ethics and Quality Assurance
___ Practice Management
___ Medicare/Medicaid

___ 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
____ Q &A Forum
____ AOL Medical Billing Forum
____ AMBA's Homepage
____ Other _______________________________________
What software program do you use to bill with:

Business and Professional Affiliations:

Formal education 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:
___ New Member's Committee
___ Newsletter Committee
___ Media and Press Committee
___ Conduct and Ethics Committee
___ Compliance and Assurance Committee
___ Policy and Regulations Committee
___ Continuing Education &Certification Committee
___ Research and Development Committee
___ Member Benefits Committee
___ Emergency Support Committee
___ Mentor Program
___ Relief and Backup Forum Moderator

Send Membership Application and Payment to:

American Medical Billing Association
4297 Forrest Drive
Sulphur, OK 73086

Or, fax your application with credit card payment to (580) 622-5810.

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