HCIA Membership Application Form

Please fill out the form below completely and press submit. Your application will be emailed to the membership manager. Please then mail your payment to the address at the bottom of the page.


First Name is required.


Last Name is required.

Address is required.

City is required.

State is required.

Zip code is required.


Email is required.

Phone number is required.

Please select membership type.










Please forward your payment to:
Bryan Hollingsworth
HCIA Executive Secretary-Treasurer
410 Holiday Rd
Lexington, KY 40502

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