Application Form:

Date:       Renewal    New

Applicant Name:

Title:   

Employer:

Employer Street Address: 

City / State / Zip: 

Work Phone: 

Mobile Phone: 

Email: 

Alternate Email: 

Membership is for those who are a healthcare provider or employee of a healthcare facility with primary responsibility for risk management functions or a participant in the risk management function on behalf of a healthcare provider, e.g., insurers, consultants and defense counsel/staff. 

PLEASE NOTE: By applying for membership in this organization you agree to have the information you provided above listed in a directory for the use of the organization’s members. 

Are you a member of the American Society for Healthcare Risk Management (ASHRM)?  
Yes   No

Do you hold any of the following certifications? (check all that apply):
CPHRM 
FASHRM (Fellow) 
DFASHRM (Distinguished Fellow)

Organization type (check as many as apply): 
Acute Care Corp/System 
Physician Office 
Extended Care 
Insurance 
Ambulatory Care
Consulting Firm 
Defense Law Firm 
Managed Care Organization 
Home Health Care 
Other:

Areas of Responsibility (check as many as apply): 
A – Actuarial Services 
B – Insurance Management 
C – Insurance Products 
D – Employee Benefits 
E – Claims Management – Professional 
F – Claims Management – General  
G – Claims Management – Workers Comp 
H – Workers Compensation 
I – In-service Education  
J – Risk Management Consultant
K – Structured Settlements
L – Defense Legal Services
M – Plaintiff Legal Services* 
N – Patient Relations 
O - Analysis/Trending
P – Safety Officer - Chairperson
Q - Quality Management
R – Contract Review 
S – Compliance Officer
T – Other__________________ 
 
* Licensed Attorneys at Law who represent Plaintiffs in personal injury litigation are not be eligible for membership

Please hit the Submit button to complete your application form: