AEHIT Membership Application

Personal Information
Name*
Prefix First Middle Last Designation
Graduate Degree(s)
Job Title*
Birth Date
Month
Day
Year
Gender*
- Male
- Female
Association Membership(s)
- ACHE
- AHA
- AHIA
- AHIMA
- HFMA
- HIMSS
- IANS
- SANS
- Other
Please Specify
Organizational Information
Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number*
Alternate Phone Number
Mobile Phone Number
Primary Email*
Enter Email Confirm Email
Alternate Email
Enter Email Confirm Email
Organization's Website
To whom do you report? (CEO, COO, etc.)
What is the name of your organization's CIO?*
First Last
Demographic Information
What are your areas of expertise?*
- CPOE
- Financial/Administrative Systems
- ICD-10 Coding
- Mobile Devices and Wireless Technology
- Health Information Exchange
- Other Clinical Systems
Which best describes your facility/organization?*
- Ambulatory Facility/Clinic
- Behavioral Health Care
- Group Practice/Clinic
- Health Insurer/Insurance Organization
- Hospice
- Hospital/Acute Care Facility
- Integrated Delivery System/Network
- Laboratory
- Managed Care
- MSO
- Nursing Home
- Specialty Hospital (Children, Cancer, Rehab, etc.)
- Other
Please Specify
Number of staffed inpatient beds
Additional Information
How did you hear about AEHIT?
Would you be interested in participating in any of the following AEHIT committees?
(Select all that apply)
- Professional Development and Education
  Solicit and schedule presenters for webinars, podcasts, and other educational and promotional media. Solicit and review KnowledgeHub submissions.
- Fall Summit Planning
  Develop agenda, solicit speakers, assist in logistics and marketing, and plan the annual AEHIT Fall Summit, taking place in San Diego, CA, from October 31 – November 2.
- Awards
  Refine criteria and market existing AEHIT Award series, solicit nominations, select winner and present at the AEHIT Fall Summit.

Personal Information

Organizational Information

Demographic Information

Additional Information