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.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download