AMBA Membership Renewal Form

Please print and send with your payment to AMBA.

Be sure to include your email address clearly written so we can send your AMBA Information and Confirmation via email.

Please do not email this application with credit card information, because it will not be secure!

___I paid online (Please fax, mail or email this registration form to AMBA for our records.)

___Individual Membership $99

___Business Membership (You may include up to 3 separate members) $199

___Add $79 for Each Additional Business Member Over 3

Order Total:$__________________

Payment Method: ___Credit Card ___Check ___Money Order ___Cashiers Check

Credit Card: ___Visa ___Master Card ___Discover ___American Express

Credit Card #:________________________________________________

Credit Card Expiration: mm______ yy_________ Security Code________________________________

Name On Credit Card (Please print clearly):______________________________________________


Member #1


Member #2


Member #3


Member #4


Business Name:_____________________________________________________________________



Phone #:_____________________________________

Fax #:_______________________________________

Please update us on your business. We'd like to hear about achievements, new or specialized training, certifications, billing specialties and other information that might help us match members to potential providers that contact us looking for assistance.

Business and Professional Affiliations:

Community activities, clubs or other:

Additional Comments:

I am interested in volunteering for the following committee(s) or programs:
___ AMBA National Advisory Board
___ Local Chapter
___ Conduct and Ethics Committee
___ Compliance and Assurance Committee
___ Policy and Regulations Committee
___ Continuing Education &Certification Committee
___ Research and Development Committee
___ Mentor Program
___ Relief and Backup Forum Moderator
___ Conference Committee

Send Membership Application and Payment to:

American Medical Billing Association
2465 E. Main
Davis, OK 73030
(580) 369-2700

Or, fax your application with credit card payment to (580) 369-2703.

Please do not email this application with credit card information, because it will not be secure!