AEHADA 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 AEHADA?
Hidden
Would you be willing to speak to your peers about AEHADA?
- Yes
- No
- Not sure
Would you be interested in participating in any of the following AEHADA committees?
(Select all that apply)
- Membership & Marketing
  Properly build, shape, and enhance our membership by recruiting healthcare IT applications and informatics leaders. Strive to help AEHIA reach specific growth goals through membership outreach and event and association marketing.
- Professional Development and Education
  Solicit and schedule presenters for webinars, podcasts, and other media. Solicit and review KnowledgeHub submissions and best practices.
- Awards and Most Wired
  Design an awards series recognizing excellence in healthcare IT applications. Solicit and review nominations for awards and recognition.
Phone
This field is for validation purposes and should be left unchanged.

Personal Information

Organizational Information

Demographic Information

Additional Information