AzHAM Annual Conference Registration

Friday, August 2, 2019

Hosted by: Mayo Clinic Hospital

Waugh Auditorium B

5777 E May Boulevard, Phoenix, AZ 85054

Membership Form / Annual Renewal Form

 

 

Check all that Apply

Name

Title

Phone #

New

Renewal

1

 

 

 

 

 

2

 

 

 

 

 

3

 

 

 

 

 

4

 

 

 

 

 

5

 

 

 

 

 

 

Organization Name:

 

Organization Address:

 

Referred by

                          (AZHAM Member / Facility Contact)

 

Conference & Annual Membership Fee $35.00 

 


 

 

 

 

 

Payment can be made over the phone or mail payment. Make checks payable to Arizona Assoc. of Healthcare Access Management.

 

To: AzHAM                                                        

Attn: Joy Everson Treasurer  Federal Tax Id = 86-0720323

P.O. Box 12485 E-Mail:    Everson.Joy@mayo.edu

Scottsdale, AZ 85267

 

 

Text Box: Please RSVP by July 15, 2019