Membership information for the California Association of Healthcare Quality

* 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)