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Please fill out the form completely.  Once completed, you may send the form immediately or print to be mailed to:
ISHRM
P.O. Box 40751
Indianapolis, IN 46240 		 

Please remember to send check or money order for $60.00 dues to the above address. Thank you.

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Name:   
Organization: 
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Certifications, 
Degrees, Diplomas and 
Professional Designations: 
Address: 
City:    State:    Zip: 
Phone:               FAX: 
E-Mail: 
Employer (Please select one):
  Acute Care Provider
        Academic Medical Center Community Hospital
        Behavioral Healthcare Military/Federal/VA
  Managed Care Provider
Ambulatory Care/Rehabilitation
Home Healthcare
Risk Management Consultant
Insurance Broker
Physician Practice Management
Law Firm
Other
 
Primary Function(s) (Please check all that apply):
  Management/Administration in a Healthcare Setting
Loss Control (Claims and/or Loss Prevention)
Quality Improvement
Insurance/Loss Financing
Attorney
Other
Are you a member of ASHRM (American Society for Healthcare
Risk Management), our national organization? Yes No
 
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