AMBA Membership Renewal 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 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: mm______ yy_________ 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:___________________________________________________________________________
City:___________________________________________State:____________Zip:_____________
Phone #:_____________________________________
Fax #:_______________________________________
Please update us on your business. We'd like to hear about achievements, new or specialized training, certifications, billing specialties and other information that might help us match members to potential providers that contact us looking for assistance.
Business and Professional Affiliations:
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
___ Conference Committee
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!