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New & Renewing Member Online Form

800-230-3163       626-793-7417          Tax ID #95-3647787

* REQUIRED FIELDS
   Application Type:   Referred by:
* Name:
Business: Facility Name:
Title:

*Address:
*City
*State
 *Zip

Home Address
City
State
 Zip
*Business Phone
Home Phone
Fax Number
*e-mail address
    
USE a capital X to indicate your choice below:
    
For publication in the CAHQ Directory, use my
 Business Home
For mailings, use my
 Business Home
Omit my name from promotions CAHQ sends via e-mail  
Omit my name from promotions CAHQ shares with non-affiliated organizations (You will still receive all CAHQ mailings.)  
I hold active status as a Certified Professional in Healthcare Quality (CPHQ)
I am a current member of the National Association for Healthcare Quality (NAHQ), a CAHQ affiliate.
RN California License#
 Registered Record Admin(RRA)#
 MD/DO License#
 Accredited Records Tech (ART)#

 Cert.Med.Staff Coord. (CMSC) #

 Cert. Prof.Cred.Specialist (CPCS) #
 
 
Other professional license/certification/accreditation.
 Type #
Type #
 
 
In Which Type of Organization/facility do you currently work? (select the 1 most appropriate description - USE a capital X)
 Acute care hospital or medical center
 Outpatient clinical facility
 Behavioral health facility
Specialty healthcare facility (e.g.,chemical dependency or rehab)
 Home health/hospice
Long term care facility
 Government agency (non-hospital)
Licensure or accreditation body
 Insurance company/PPO
Managed care organization
 Private review organization
Health maintenance organization
 Corporate or network/system headquarters
 Consultant
 None of these apply
 
What is/are your area(s) of expertise? (check all that apply)
 Quality management/improvement
 Risk management
 Care/case/utilization management
 Medical staff services
 Managed care
 Administration
 Information management
 Infection control
 Corporate compliance
 Ambulatory/rehabilitative care
 Behavioral health
 Long term care
 Home care
 Nursing
 Patient Safety  
   Which best describes your current position?
Senior management Middle Management
Supervisory Staff
Consultant
  How many years of experience do you have in the healthcare quality field?
  Have you been a CAHQ member before?    If yes, when? (year)

 
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