UAHQ Membership Application Individual membership is available to persons involved in the health care field. Individual members are eligible to vote, hold office, and serve on committees. Benefits include electronic communication including the newsletter and even announcements and reduced rates on educational opportunities. Question Title * 1. Contact Information Name Title and Organization Mailing Address City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Membership dues for the State Association are $45. Please indicate your method of payment.Note: UAHQ dues cannot be deducted as a charitable contribution, but can be deducted for federal income tax purposes as an ordinary and necessary business expense. Consult your tax advisor for individual assistance. Check- please print a copy of this form and mail it with your check to:Utah Association for Healthcare QualityPO Box 521073Salt Lake City, UT 84152 Venmo- I will send $45 via Venmo to @UTAHQ Help UAHQ maintain an accurate membership database by completing the information below. This information is a key resource in producing educational products, service, and networking opportunities.Please check all boxes that apply Question Title * 3. Tell Us about yourself Degree Level Credentials Years of experience in healthcare quality Position (Regardless of Title) Organization/ Facility Type Question Title * 4. Primary Area of Responsibility/ Interest Quality/ Performance Improvement Infection Prevention Utilization Review Medical Staff Services Care Management Risk Management Health Information Other (please specify) Question Title * 5. Are you a member of the National Association of Healthcare Quality (NAHQ)? Yes No Question Title * 6. Would you be interested in service as a future officer or on a committee? President Secretary Treasurer Member at Large Education Committee Communications Legal/ Legislative Question Title * 7. Do you approve of your name being released to the UAHQ membership? Yes No Thank you for your membership application, we look forward to your participation with this organization. Please print this survey prior to pressing submit if you plan to pay by check. SUBMIT