MASSACHUSETTS ASSOCIATION FOR HEALTHCARE QUALITY
MEMBERSHIP APPLICATION
PLEASE PRINT
MEMBERSHIP TYPE: ACTIVE RETIRED ___ORGANIZATION NAME____________________________________________________________POSITION___________________________________
INDIVIDUAL OR ORGANIZATION CONTACT
ORGANIZATION NAME___________________________________________________________________________________________
ORGANIZATION ADDRESS________________________________________________________________________________________
CITY_______________________________________________________STATE___________ ZIP____________________
WORK PHONE__________________________________EXT. FAX ________________________
E-MAIL ADDRESS _______________________________________________________________________
WE RECOMMEND MAHQ MAILINGS BE SENT TO YOUR HOME. THIS INFORMATION WILL NOT BE PUBLISHED UNLESS IT IS THE SAME ABOVE – FOR DATABASE AND MAHQ MAILING USE ONLY.
HOME ADDRESS______________________________________________________________________________________________
CITY__________________________STATE___________ ZIP__________ HOME PHONE ______________
SEND MAIL TO : HOME _ WORK __
EDUCATIONAL BACKGROUND (PLEASE CHECK ALL THAT APPLY TO YOU)
_ ASSOCIATES DEGREE LPN RN RHIT RHIA BSN OTHER BACHELOR’S DEGREE MSW OTHER MASTER’S DEGREE _JD MD PhD ___OTHER (SPECIFY)___________________________________________
ORGANIZATION / FACILITY TYPE (Select One)
_ GENERAL /ACUTE PSYCH/SUBSTANCE REHAB/SNF CHRONIC/LONG TERM
CONSULTING/SERVICE FIRM AMBULATORY/OFFICE HOME HEALTH MILITARY V.A. MANAGED CARE/INSURANCE EDUCATION PEDI
OTHER (SPECIFY)_______________________________________
POSITION-REGARDLESS OF TITLE (Select One)
_ ADMINISTRATOR/CEO ANALYST/COORDINATOR/SPECIALIST CONSULTANT DIRECTOR/MANAGER SUPERVISOR VICE PRESIDENT STAFF NURSE PHYSICIAN
STAFF ASSISTANT OTHER (SPECIFY)______________________________________
PRIMARY AREA OF RESPONSIBILITY / INTEREST / PRACTICE (Select One)
_ CASE MGMT PI/CQI/TQM QA/UR INFECTION CONTROL MEDICAL RECORDS NURSING SAFETY RISK MANAGEMENT UR/UM MEDICAL STAFF SERVICES / MEDICAL AFFAIRS REG COMPLIANCE OTHER (SPECIFY)_____________________________________
ARE YOU A MEMBER OF NAHQ? _ YES NO ARE YOU CERTIFIED IN HEALTHCARE QUALITY (CPHQ)? YES _ NO
IS THIS YOUR FIRST APPLICATION TO MAHQ? _ YES NO RENEWAL? ORIGINAL MEMBERSHIP YEAR: ___
THANK YOU. PLEASE MAIL THE COMPLETED APPLICATION AND $50.00 INDIVIDUAL OR $250.00 ORGANIZATION MEMBERSHIP FEE TO:
MAHQ
39 B Grandview Ave
Quincy, MA 02170