Membership RenewalProvide preferred contact information below

Name/ID: ________________________________________________

Title: ___________________________________________________

Company: _______________________________________________

Address: ________________________________________________

City/State/Zip: ___________________________________________

Phone: _______________________________ Home Work Mobile

Email: ___________________________________________________

Membership Options

CRA Pathway Membership - NEW! $300/yrMembership through December 31, Subscription to Radiology Management, Includes CRA application fee*, Virtual CRA Exam Prep Workshop, 25 Rewards Points for use on AHRA products. *must use CRA application fee credit within membership term.

Standard Membership $210/yrMembership through December 31, Subscription to Radiology Management, 10 Rewards Points for use on AHRA products.

Standard Membership $18/mthPaid MonthlyMembership through December 31, Subscription to Radiology Management, 10 Rewards Points for use on AHRA products. By choosing this option you agree to 12 monthly payments of $18/each with automatic renewal on January 1. You may cancel after 1 year.

PAYMENT OPTIONS

Checks may be made out to AHRA and mailed to AHRA, 490-B Boston Post Rd., Suite 200, Sudbury, MA 01776

Circle one: VISA / MASTERCARD / AMERICAN EXPRESS / DISCOVER

Card Number: ____________________________________________________ Card Expiration Date: ____________________________________ Authorization for MONTHLY AHRA Membership dues payment: By signing below, I authorize AHRA to automatically debit the credit card listed above in the amount of $18.00 monthly for 12 payments and $18.00 monthly thereafter until either party notifies the other in writing that they wish to cancel.

Signature: ______________________________________________________ Date: ________________

Add an Education Foundation Donation

Add a voluntary tax-deductible donation to help AHRA and the Education Foundation grow its cornerstone programs and projects: awards, scholarships, and grants.

Yes, I would like to donate $____________

TOTAL $____________

PHONE:1-800-334-2472Mon-Fri, 9am-5pm ESTFAX:978-443-8046

EMAILpayments@ahra.org

ONLINEwww.ahra.org

DIRECT ACH PAYMENT:Bank of America22 Union Ave., Sudbury, MA 01776Routing: 011000138Account: 4660 0895 5018

1. Is your organization (select one): □ A stand-alone facility □ Part of a multi-hospital system 2. Organization status (select one): □ Not-for-profit □ For profit □ Government 3. Type of employer (check all that apply):

Hospital Non-Hospital □ Academic (medical school affiliated) □ Imaging center □ Pediatric □ Multi-specialties physician office (not radiology) □ Long-term care □ Primary care clinic □ Community □ Radiologist private office □ Rehabilitation (greater than 75% patients) □ Mobile service □ Multiple hospitals □ Commercial □ Multiple facilities □ Consultant 4. Licensed hospital bed size (if applicable):

□ 0-99 □ 100-249 □ 250-399 □ 400-599 □ 600+ 5. Annual imaging procedure volume (in thousands):

□ 0 □ 20-29 □ 75-99 □ 150-174 □ 1-9 □ 30-49 □ 100-124 □ 175-199 □ 10-19 □ 50-74 □ 125-149 □ 200+ 6. Area(s) for which you have management responsibility (please check all that apply):

□ Angiography □ Interventional radiology □ Radiation therapy/oncology □ Bone densitometry □ Inventory planning/purchasing □ Radiology support services (e.g. film library) □ Budgeting, billing, reimbursement □ Laboratory services □ Rehabilitation □ Cardiac catheterization □ Mammography/breast imaging □ Respiratory therapy □ Cardiology (EKG, stress, Holter, Echo) □ Marketing □ Results reporting □ Cardiopulmonary □ Medical physics □ RIS/HIS □ Centralized scheduling □ Mobile services □ Ultrasound □ Centralized transportation □ Molecular imaging □ Urgent care □ Coding □ MRI □ Vascular lab (non-invasive) □ Compliance □ Neurodiagnostics (EEG, EMG, sleep center) □ Voice recognition □ Construction/renovation/design □ Nuclear Medicine □ Workforce planning □ CT □ Outpatient imaging centers □ X-ray □ DR/CR □ PACS □ Breast center □ Education (RT program) □ PET, PET/CT □ Cardiac cath lab □ EMR/EHR □ Pharmacy □ Environmental services/facilities

□ Endoscopy □ Purchasing department □ Noninvasive cardiology □ Equipment planning/purchasing □ Quality improvement □ Scheduling □ Fusion imaging □ Radiation safety □ Transport

7. Registration/certifications/licenses you hold:

□ RT □ RDCS □ LPN □ CVT □ CIIP □ RDMS □ RVT □ RN □ Certified Radiology Administrator (CRA) □ Other (please specify) _________________________________________ 8. Membership in other organizations:

□ ASRT □ ARIN □ SDMS □ CLMA □ RBMA □ SIIM □ SNM □ ACHE □ Other (please specify) ______________________________________________________________________ 9. Years of responsibility in level:

________ Administration/management at one or multiple dept/facilities ________ Supervisor ________ Other (please specify) ________________________________ ________ Chief technologist 10. Current title (please select most relevant):

□ Director □ Technologist □ CEO/COO □ Administrator □ Vendor □ Chief/Lead Technologist □ Manager □ Consultant □ Educator □ Supervisor □ President □ VP □ Radiologist □ Student □ Other (please specify______________

For AHRA membership information call Toll-Free (800) 334-2472 (US only) ● (978) 443-7591 ● Website: www.ahra.org