The purpose of CHRMS is to advance the ... - CHRMS Chicago
MEMBERSHIP APPLICATION
|Date | |Renewal | |New |
| | | | | |
|Applicant Name | | | | |
| |First |Middle |Last | |
|Title | |Professional Designation | | |
| | | | | |
|Employer | |
| | | | | |
|Employer Address | |
| | | | | |
|City/State/Zip | |
| | | | | |
|Work Phone | |Email | |
| | | | | |
|Fax | | | | |
Are you a member of the American Society for Healthcare Risk Management (ASHRM)? Yes No
Organization type (check as many as apply):
| |Acute Care Corp/System | | |Physician Management |
| |Long Term Care/Rehabilitation | | |Insurance Company |
| |Ambulatory Care | | |Insurance Broker |
| |Defense Law Firm | | |Consulting Firm |
| |Home Health Care | |Other: | |
Areas of Responsibility (check as many as apply):
| |A – Actuarial Services | | |K – Structured Settlements |
| |B – Insurance Services | | |L – Defense Legal Services |
| |C – Insurance Products | | |M – In-house Counsel |
| |D – Employee Benefits | | |N – Patient Relations |
| |E – Claims Mgmt. – Professional | | |O – Incident Report Analysis/Training |
| |F – Claims Mgmt – General | | |P – Safety Officer |
| |G – Claims Mgmt – Workers Comp | | |Q – Quality Mgmt |
| |H – Workers Compensation | | |R – Contract Review |
| |I – In-service Education | | |S – Compliance Officer |
| |J – Risk Mgmt Consultant | | |T – Plaintiff Legal Services |
| | | |Other: | |
|ANNUAL DUES |
|*Annual dues are nontransferable. |
|Applying for Active membership | |
|$50.00/yr. |Active Membership – Individuals professionally involved in the field of healthcare risk management and patient safety,|
| |whose job responsibilities include healthcare risk management, patient safety, providing underwriting, marketing or |
| |brokering functions for an insurance company, legal or consulting services to healthcare providers, or are interested |
| |in the field of healthcare risk management and patient safety. |
|Applying for Academic membership | |
|$25.00/yr. |Academic Membership – Full-time students who are registered at an institution of higher learning in a program that is|
| |related to healthcare risk management or patient safety. |
Application Process:
1. Please complete this application and mail with check, payable to CHRMS, to:
CHRMS – Chicagoland Healthcare Risk Management Society
P.O. Box 06229
Chicago, IL 60606-0229
*Please note that in the event the application is not approved, your dues remittance will be promptly refunded.
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