KHIMA Distinguished Member Nomination - Kentucky Health Information Management Association

KHIMA Distinguished Member Nomination

KHIMA Distinguished Member Nomination

Nominee Information

Name

Name

Name

Name

Email

Phone

Address

Address

Address

Address

Address

Address

Address

Nominator Information

Name

Name

Name

Name

Email

Phone

Address

Address

Address

Address

Address

Address

Address

Leadership Roles

Local, State, National Levels and/or Other Affiliated Associations

Impact on HIM

Publications, Teaching in AHIMA-Approved Education Programs and/or Other HIM Instructions/Contributions

Reason for Nomination

Why have you chosen to nominate this member for the distinguished member award? Please provide a well written statement that is at least one paragraph.

Signature

Signature of

Date

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