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: