MEMBERSHIP APPLICATION FORM
Apply for membership with the Healthcare Information Management Association of the Philippines. Please complete all required sections and upload supporting documents.
COMPANY PROFILE
Company Name
*
Address
*
Email Address
*
Tel. No.
*
Format: (000) 0000-0000.
URL
*
Nature of Business
*
Specific Healthcare program/campaign
*
(e.g. RCM, Coding, Voice, Billing, Pharma, etc.)
AUTHORIZED REPRESENTATIVES
(1) Primary Representative - Name
*
(1) Designation
*
(1) Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
(1) Email
*
example@example.com
(2) Secondary Representative - Name
*
(2) Designation
*
(2) Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
(2) Email
*
example@example.com
LIST OF OFFICERS WITH NAME AND DESIGNATION
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INDUSTRY BASELINE DATA
Number of Full Time Employees
*
Latest for healthcare business only
Latest Estimated Annual Revenue in USD
*
Closing revenue of past year for healthcare business only
Number of Full Time Employees
*
Latest FTE count for all business + healthcare
Latest Estimated Annual Revenue in USD
*
Closing revenue of past year for all business + healthcare
MEMBERSHIP CATEGORY
Nature of Business
*
ITBPM Healthcare Services and Solutions Provider
Vendor/Enabler
Association Partner
MANDATORY DOCUMENTARY REQUIREMENTS
Upload Supporting Documents
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SIGNATURES / CONSENT
Prepared by
*
Designation
*
Signature
*
Date Prepared
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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