This form is used by health information exchange (HIE) organizations, participants of HIE organizations, government agencies, and associations who wish to participate in CAHIE activities. Information in this application will be used by CAHIE solely for the purpose of determining whether the Applicant meets the eligibility requirements for participation. CAHIE reserves the right to request additional information needed to verify eligibility. Upon receipt, the application will be reviewed by the Executive Committee for recommendation to the Board of Directors.
Membership Type (select one)
All Members may participate in Committees and Workgroups and suggest topics for or present at the Knowledge Network, are included on CAHIE’s exclusive member mailing list and receive invitations to CAHIE activities, may use the CAHIE logo on their marketing material, and are included as a CAHIE Member on our web site.
ClassCostDescription
☐Large HIE Organization$5,000 annuallyHIOs with greater than $50million in annual revenue
☐Small HIE Organization$2,500 annuallyHIOs with less than $50million in annual revenue
☐Junior HIE OrganizationNo costHIOs in the first two years of incorporation that do not yet have the budget for full membership
☐Affiliate Member$500 annuallyClinic, hospital, or other participant of a Member HIO (large or small HIE organization)
☐Non-HIE Association$1,000 annuallyNot-for-profit associations of health IT stakeholders interested in supporting HIE
☐Government OrganizationNo costAny federal, state, or local government agency interested in supporting HIE
Organization Information
Organization Name:Click or tap here to enter text.
AddressStreet:Click or tap here to enter text.
City, State, ZIP:Click or tap here to enter text.
Web Site:Click or tap here to enter text.
RepresentativeName, Title:Click or tap here to enter text.
Phone, Email:Click or tap here to enter text.
AlternatesNames, Emails:Click or tap here to enter text.
Describe the services that your organization provides, and the members, participants, and/or customers represented.
Click or tap here to enter text.
Statement of Interest
Please provide a concise statement of why your organization is interested in participating in CAHIE.
Click or tap here to enter text.
Signature
I hereby apply for membership/affiliate membership in the California Association of Health Information Exchanges and resolve to abide by the CAHIE Bylaws and operating policies if accepted into membership.
Signature:
Print Name and Title:Click or tap here to enter text.
Date:Click or tap here to enter text.
Completed and signed forms should be returned to CAHIE at .
Updated: 01-04-20181