Group Membership Application

Welcome to the first step in unlocking exclusive benefits and streamlining your organization's experience with a Group Membership! SHSMD Groups, consisting of 10 or more members, enjoy substantial savings, simplified billing, and a host of additional advantages.

Provide your details below to initiate your group membership, and someone will get in touch with you about the next steps.

If you have any questions or have not been contacted within 48 hours, please email SHSMD at shsmd@aha.org.

Question Title

* 1. Organization Information

Name

Street Address

City

State

Zip

Phone Number

Fax Number

Question Title

* 2. I am signing up as a:

Health Care Provider-Based Group

Solution Provider Group (Standard)

Solution Provider Group (Premium)

Question Title

* 3. Executive Sponsor

This person is a SHSMD member, familiar with SHSMD’s benefits, and will be contacted to relay the group newsletter. They will also be responsible for letting SHSMD know about the group’s needs and what would be helpful.

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 4. Group Lead

This person is responsible for group payments and member changes.

AHA ID (for current SHSMD members only)

First Name

Last Name

Title

Street Address (if it's the same as the org, skip to phone number)

City

State

Zip

Phone Number

Fax Number

Question Title

* 5. Please attach your Member Roster list in .PDF, .DOC or .DOCX format and include the following (separate) fields for each member:

First Name; Last Name; Title; Organization; Street Address; City; State; Zip Code; Phone Number; Email

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 1. Organization Information

Question Title

* 2. I am signing up as a:

Question Title

* 3. Executive SponsorThis person is a SHSMD member, familiar with SHSMD’s benefits, and will be contacted to relay the group newsletter. They will also be responsible for letting SHSMD know about the group’s needs and what would be helpful.

Question Title

* 4. Group LeadThis person is responsible for group payments and member changes.

Question Title

* 5. Please attach your Member Roster list in .PDF, .DOC or .DOCX format and include the following (separate) fields for each member:

* 3. Executive Sponsor

This person is a SHSMD member, familiar with SHSMD’s benefits, and will be contacted to relay the group newsletter. They will also be responsible for letting SHSMD know about the group’s needs and what would be helpful.

* 4. Group Lead

This person is responsible for group payments and member changes.