NEBA Membership Form

NEBA Membership Application

Please mail a separate, completed form and membership fee for each member.

1. Full Name

2. Date

3. Title

4. Company

5. Mailing Address

6. City

7. State

8. Zip Code

9. Phone Number

10. Fax Number

11. Email Address

12. Please select your membership type and payment amount:
	I am enclosing a check or money order of $129 for individual membership, and electronic newsletter.	I am enclosing a check or money order of $169 for individual membership, and printed newsletter to be delivered via the USPS.

13. Do you wish to be included on the membership roster?
	Yes, please include my name on the roster.	No, thank you.

14. We'd like to learn more about you:
When did you start your medical billing business?

What software do you use?

Which vendor(s) do you use?

How many medical practices are you currently serving?

How many physicians are you serving?

What are some of their specialties?

Signature

Member Signature

Completed form should be printed and mailed to:

NEBA
National Electronic Billers Alliance
2226-A Westborough Blvd. PMB 504
South San Francisco, CA 94080