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HFMA Store Order Form

Ship to

Company/Organization
Name
HFMA Member No.
Address
No P.O. Boxes please
City
State
Zip
Day time phone for shipping address
Product Qty Unit Price Total Price

2007 Glossary

1 copy $30.00
11+ copies $25.00

HFMA Principles and Practices Board Issue Analysis 05-01

1 copy (non-member price) $17.50
1 copy (non-member price) $22.00
10 - 49 Copies $15.00
50 - 99 Copies $12.50
100 or more $10.00

Compliance Checklists

For Clinical Laboratories $25.00
For Group Physician Practices $25.00
For Home Health Agencies $25.00
For Medicare + Choice $25.00
For Nursing Facilities $25.00
For Third-Party Billing Companies $25.00
For Durable Medical Equipment $25.00
Merchandise Total
Tax *Illinois residents only. Add 7.75% of merchandise total for tax.
Expedited Shipping (Optional) $25.00
Total Price
Note: Please allow 2 business days for processing orders. If expedite shipping is not requested, all orders are shipped via UPS ground service and arrive in 5-10 business days, contingent on destination. UPS cannot ship to a P.O. Box number.

Payment Information

Note: Make checks payable to HFMA and include the printed form with your payment. Mail to: HFMA Attention: Member Service Center, 2 Westbrook Corporate Center, Suite 700, Westchester, IL 60154
Charge my: Visa Mastercard
American Express Discover Card
Card Number:
Expiration Date:
Cardholder's Name:
Cardholder's Signature:
(Type in your name, which will be taken as your signature.)
Cardholder's Phone Number:
Cardholder's Fax Number: