Get documents about "Society for Imaging Informatics in Medicine
Document Sample
Society for Imaging Informatics in Medicine
Institutional Membership Application
Institution: SIIM Membership
Name: ____________________________________________ The institutional membership focuses on bringing together a
team of professionals from the same institution into SIIM (i.e.
Address: __________________________________________ physician, healthcare administrator, physicist, IT, PACS
Administrator, etc.) who as a group are exploring and applying
City:______________________________________________ advanced technology information systems to improve the
delivery of medical imaging services. The resources of SIIM
State: ____________________________________________ are applied to help educate individuals sponsored by their
institutions of PACS, and image management technology
Zip: ______________________________________________ through publications, meetings, seminars, and personal
communications. The institutional membership plan is also
Country: __________________________________________ intended to foster a continuing joint effort between SIIM
institutional and corporate members to explore and address
Phone: ____________________________________________ issues involving PACS and IS integration through education
and shared experience.
Fax: ______________________________________________
SIIM Membership Category
Website: __________________________________________ (Indicate selection below)
Primary Contact: US/Canadian Institutional Membership $600.00 –
US/Canadian membership is available to institutions involved
in the medical imaging field and which are located in the US or
Salutation: Dr. Mr. Ms.
Canada.
First Name: ________________________________________ International Institutional Membership $800.00 –
International membership is available to institutions involved
Middle Name: ______________________________________ in the medical imaging field and which are located outside of
the US or Canada.
Last Name: ________________________________________
Membership Benefits
Degree: ________________ Male Female
• Four SIIM annual memberships for employees. SIIM
Title: _____________________________________________ members will receive the Journal of Digital Imaging (JDI)
published quarterly, and SIIM News.
Department: _______________________________________
• Complimentary copy of the SIIM University Syllabus
Organization:_______________________________________ • Discounts on meeting registration fees and SIIM
publications (with volume discounts for additional copies).
Address: __________________________________________ • Special consideration given to institutional members in the
site selection process for hosting the annual meeting of the
City/State/Zip: _____________________________________ Society for Imaging Informatics in Medicine.
Country: __________________________________________
• Special consideration when applying for SIIM informatics
grants.
Phone: ____________________________________________ • 50% reduction in participation fees in the IRISS, FUSUN, &
SUMMIT user groups that exchanges innovation solutions to
Fax: ______________________________________________ application problems.
• Invited participation in the SIIM Vendor/Provider
Email: ____________________________________________ Partnership Program.
• Receive consultation on individual needs from experienced
SIIM members through the expert hotline.
Payment Information
• Inclusion on SIIM website institutional member listing with
Signature: _________________________________________ link back to institution's web site.
Date: _____________________________________________
• 10% discount on classified advertising in SIIM News.
• Complimentary SIIM membership labels for educational
Payment Options: VISA MasterCard programs
American Express Discover Card
Check enclosed Submission Instructions
$0.00
Total Paid: $____________
Please return your: (1) completed application form and
Credit Card Number: _________________________________ (2) payment to:
Expiration Date (MM/YY): _____________________________ Society for Imaging Informatics in Medicine
19440 Golf Vista Plaza, Suite 330
Name on credit card:_________________________________ Leesburg, VA 20176
Zip Code of Credit Card billing address Phone 703-723-0432
(for confirmation of US cards only): _____________________ Fax: 703-723-0415
Email: info@siimweb.org
Security Code (from back of card): ______________________ Web: www.siimweb.org
Society for Imaging Informatics in Medicine
Institutional Membership Application
Sponsored Member #1 Sponsored Member #2
Salutation: Dr. Mr. Ms. Salutation: Dr. Mr. Ms.
First Name: ________________________________________ First Name: ________________________________________
Middle Name: ______________________________________ Middle Name: _______________________________________
Last Name: ________________________________________ Last Name:_________________________________________
Degree: ______________ Male Female Degree: _____________ Male Female
Title: _____________________________________________ Title:______________________________________________
Department: _______________________________________ Department: _______________________________________
Organization:_______________________________________ Organization: _______________________________________
Address: __________________________________________ Address:___________________________________________
City/State/Zip: _____________________________________ City/State/Zip: ______________________________________
Country: __________________________________________ Country:___________________________________________
Above Address is: Work Home Above Address is: Work Home
Phone: ____________________________________________ Phone: _____________________________________________
Fax: ______________________________________________ Fax: _______________________________________________
Email: ____________________________________________ Email:______________________________________________
Occupation Specialty Occupation Specialty
(select one category – best match) (select one category – best match) (select one category – best match) (select one category – best match)
Physician Radiology Physician Radiology
Medical Physicist Cardiology Medical Physicist Cardiology
Technologist Nuclear Medicine Technologist Nuclear Medicine
Healthcare Administrator Oncology Healthcare Administrator Oncology
PACS Administrator Information Systems PACS Administrator Information Systems
Health Info Professional Health Info Professional
Scientist/Researcher Other _______________ Scientist/Researcher Other _______________
Computer Scientist Computer Scientist
Engineer Engineer
Educator Educator
Vendor/Consultant Vendor/Consultant
Student/Resident Student/Resident
Society for Imaging Informatics in Medicine
Institutional Membership Application
Sponsored Member #3 Sponsored Member #4
Salutation: Dr. Mr. Ms. Salutation: Dr. Mr. Ms.
First Name: ________________________________________ First Name: ________________________________________
Middle Name: ______________________________________ Middle Name: _______________________________________
Last Name: ________________________________________ Last Name:_________________________________________
Degree: ______________ Male Female Degree: _____________ Male Female
Title: _____________________________________________ Title:______________________________________________
Department: _______________________________________ Department: _______________________________________
Organization:_______________________________________ Organization: _______________________________________
Address: __________________________________________ Address:___________________________________________
City/State/Zip: _____________________________________ City/State/Zip: ______________________________________
Country: __________________________________________ Country:___________________________________________
Above Address is: Work Home Above Address is: Work Home
Phone: ____________________________________________ Phone: _____________________________________________
Fax: ______________________________________________ Fax: _______________________________________________
Email: ____________________________________________ Email:______________________________________________
Occupation Specialty Occupation Specialty
(select one category – best match) (select one category – best match) (select one category – best match) (select one category – best match)
Physician Radiology Physician Radiology
Medical Physicist Cardiology Medical Physicist Cardiology
Technologist Nuclear Medicine Technologist Nuclear Medicine
Healthcare Administrator Oncology Healthcare Administrator Oncology
PACS Administrator Information Systems PACS Administrator Information Systems
Health Info Professional Health Info Professional
Scientist/Researcher Other _______________ Scientist/Researcher Other _______________
Computer Scientist Computer Scientist
Engineer Engineer
Educator Educator
Vendor/Consultant Vendor/Consultant
Student/Resident Student/Resident
Related docs
