Wisconsin Association Medical Staff Services WAMSS 2018 Membership Application
Membership Year - January 1 - December 31
APPLICATION INFORMATION
(Membership is not transferable.)
Email address *
MEMBERSHIP CATEGORY
ACTIVE MEMBERSHIP: Those individuals who are currently engaged in medical staff activities, or non-hospital-based credentialing services, or individuals who have achieved and maintain current CPMSM and/or CPCS certification if not
currently engaged in medical staff service activities. Required to pay dues, eligible to vote and eligible to hold office.

ASSOCIATE MEMBERSHIP: Those individuals who are interested in the overall aims and objectives of this organization, but not engaged in medical staff service activities as outlined in the Active category. Required to pay dues, eligible to vote
and eligible to hold office.

Membership Type *
Annual Dues: $65.00 "Early Bird" Dec 1 - Feb15. After Feb 15 $75.00
Credit Card - Please pay through our website (www.wi-wamss.org ) by clicking the “Buy Now” button (please note that there is an additional $3.00 charge to cover the cost for using PayPal).
PLEASE forward your PayPal confirmation email to Membership Chair.

Check payable to WAMSS – Please complete this application, and mail with payment to: WAMSS Treasurer, Dana Amacher, Aspirus Wausau Hospital, 333 Pine Ridge Blvd, Suite 1-905, WAUSAU, WI 54401

Select your payment option *
PAYMENT MADE VIA PAYPAL: Enter Receipt # *
Required
Name: *
Your answer
Certifications *
Job Title *
Your answer
Organization *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Phone *
Your answer
Fax *
Your answer
Are you new to the medical staff/credentialing field? *
Is this your first time joining WAMSS? If YES, please complete "OTHER" How did you learn about WAMSS? *
Required
What are your primary work responsibilities (i.e., credentialing verification, CME, etc.): *
Your answer
If you are not currently CPMSM or CPCS certified, are you interested in becoming certified? *
Does your current position require you to be knowledgeable in the following standards? *
Required
Please provide the URL Address used to produce Hospital Affiliation Verification letters of providers credentialed with your Organization. i.e. http://www.namss.org/NAMSSPASS.aspx If None, please select N/A. This information is being requested to create a resource available to WAMSS Members. *
Required
A copy of your responses will be emailed to the address you provided.
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