Advantage 2K Medical Billing Company
AMBA Registration Form
Form Number MHEC-amba
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 of you Registration via email.
___I Joined and paid online
___Single AMBA Membership $99
___Business AMBA Membership for up to Three Members $199
___I am enclosing a check with my registration form
___I am paying by credit card on this form (DO NOT EMAIL CREDIT CARD INFO)
___Visa Card #________________________Exp________
___Master Card #_________________________Exp________
___AMEX Card #__________________________Exp________
___Discover Card #__________________________Exp________
Name on card__________________________________
Name and email address of each Member:
Business Name:
Address:
City ST Zip:
Phone Number:
Email Address(es):
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 Dues to AMBA's Main Office at:
American Medical Billing Association
4297 Forrest Drive
Sulphur, OK 73086
Or, fax your form with a credit card payment to (580) 622-5809. Be sure to include the expiration date and name on the card when paying by credit card. Visa, MC and Discover accepted.
This form generated from AMBA East Coast Office Website