Physician Hospital Alliance

2115 Leiter Road, Suite 400, Miamisburg, OH  45342

Phone 937-384-6950 - Fax 937-384-6949

www.khnetwork.org/pha

 

 

       PHA 2008 Dues Invoice                                              

 

 

     For PHA Physician Member:  ____________________________________________

 

     Group or Practice Name:  ______________________________________________

 

     Please provide us with your National Provider Identifier Number (NPI):  ____________

 

 

     2008 Dues  ............................................................................................$275.00

 

 

     2008 Dues including HealthGrades Website Assessment .......................$366.00

 

 

We can now accept payments with MasterCard or Visa.

  Please fill out the information below:

 

 

Card Holder:  __________________________________________________

 

Card Type:  ___________________________________________________

 

Credit Card Number:  ___________________________________________

 

 Expiration Date:  _______________________________________________

 

 

 OR, make check payable to:  “Physician Hospital Alliance”

 Please return payment to the address below:

 

Physician Hospital Alliance

2115 Leiter Road, Suite 400

Miamisburg, OH  45342-3659

 

If you have any questions please call Carol Baugh at (937) 384-6951.  Thank you.

 

 

Please Note:  If the enclosed payment reflects membership dues for more than one physician in your group, please list each physician’s name.