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Physician Hospital Alliance 2115 Leiter Road, Suite 400, Miamisburg, OH 45342 Phone 937-384-6950 - Fax 937-384-6949 www.khnetwork.org/pha |
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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. |
