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 #:_______________________________________
Date Business Started:_______________________
___ I am new and don't have any clients yet
___ 1-3 clients
___ 4-8 clients
___ 9 or more clients
My billing specialty is:
I am interested in continuing education courses covering:
___ Coding
___ Marketing and Prospecting
___ Compliance
___ Small Business Management
___ Ethics and Quality Assurance
___ Practice Management
___ Medicare
___ Medicaid
___ Information Systems &Software Installations
How did you learn about AMBA?
(NOTE: This information is important so members that refer others can earn extended membership time at no
charge)
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
____ Medbill Discussion Mail List (OneList)
____ 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!