User Account Details
Username:
Email address for login
Password
Company Details
Name of Applicant:
(Company or Individual)
Company Address:
Local Contact Numbers:
Local Landline
Local Fax
US Contact Numbers:
US Landline
US Fax
Website(URL):
Email Addresses:
Contact Persons
Name of Primary Representative:
Title
First Name
Last Name
Position Title:
Mobile Number:
Name of Secondary Representative:
Title
First Name
Last Name
Position Title:
Mobile Number:
Membership Category for which you are applying
Membership Category:
Membership Category Voting Annual Dues
Clinical Documentation Service Providers
Companies engaged in healthcare information records processing/clinical documentation outsourcing services
Yes PHP 00.00
HIM Training Providers
(Companies engaged in Technology and IT Solution development for healthcare information records processing/clinical documentation
Yes PHP 00.00
Healthcare IT Providers
Companies engaged in education and training for healthcare information records processing/clinical documentation outsourcing services
Yes PHP 00.00
Vendors/Corporate Partners
No PHP 00.00
Association Partners
No PHP 00.00
Affiliates/Professionals
No PHP 00.00
Privacy Statement


Company Applicant Profile
Company Name:
Primary Address:
Date Established:
Local Contact Numbers:
Local Landline
Local Fax
US Contact Numbers:
US Landline
US Fax
Website(URL):
Email Addresses:
Services/s Offerings
Please check all that apply.






























     
Company Details...
Company Size:
Business Organization:
Business Type:
Business Ownership:
For Sole Proprietorship/Partnership:
Name Of Owners:
For Corporation:
Name Of Board of Directors:
Names Positions
Production Facility Profile (For Clinical Documentation Service Providers only)
Number of Production Employees:

Number of Operation Sites/Branches

Training Center Profile (For HIM Training Providers only)
Number of Branches:

Number of MT Graduates Last Year:

Client Profile
Please check all that apply.











     
Membership in Other Trade/Industry Organizations

Please specify: