CDIA Membership Application

Payment Plans Now Available

Quarterly and Bi-annual options available
Please download the membership application or contact CDIA for details

Please refer to the CDIA website for information on the benefits included in each membership category. Each Gold, Silver and Bronze member must designate at least one primary voting company representative. The primary company representative also will receive the CDIA e-newsletter, subscription to Health Data Matrix, and other announcements. The primary representative may be changed at any time by notifying the CDIA office by phone, fax, or e-mail.

A downloadable application is available here.

Choose one: I am a current CDIA member
I was a CDIA member previously
I have never been a CDIA member.
Company:
Business Address:
City:
State/Province:
Zip/Postal Code:
Country (required if no postal code):
Phone:
Fax:
Website:

Company Representatives to CDIA
Primary Representative & Voting Member
First Name:
Last Name:
Title:
Email:
Telephone:
Company Representative
First Name:
Last Name:
Title:
Email:
Telephone:
Executive/Administrative Assistant
First Name:
Last Name:
Title:
Email:
Telephone:
Accounting Representative
First Name:
Last Name:
Title:
Email:
Telephone:

Company Profile
Years in Business
 Number of Offices
 Total Number of Employees
Type of Business (Check all that apply)
Medical Transcription Service Provider
Technology Developer/Provider
Educational Facility
Medical Provider
Ancillary Service Provider
Coding Provider
EMR Provider
Other: 		Total Revenue



 How did you learn about CDIA? (Check all that apply)
CDIA Member:
Internet Search
Social Networking Site
Web Ad
Industry Publication
Industry Convention/Tradeshow
Other:

Membership Type

Please select one of the following annual membership types. For more information on membership types, please see the CDIA website.

Payment Information
Please select a payment plan:

Total Amount of Membership Order: $
Amount to be charged now: $
Card Type:
Cardholder name (as it appears on card):
Card number:
Card Expires: Month Year