AEHIS 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
Best Phone Number to Reach You*
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?*
- HIPAA
- Data Security
- Electronic Health Records (EHRs)
- Data Management in the cloud
- Health Information Exchange
- Mobile Devices and Wireless Technology
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 AEHIS?
Hidden
Would you be willing to speak to your peers about AEHIS?
- Yes
- No
- Not sure
Would you be interested in participating in any of the following AEHIS committees?
(Select all that apply)
- Professional Development & Education
  Solicit and schedule presenters for webinars, podcasts, and other AEHIS media events. Solicit and review KnowledgeHub submissions and best practices.
- AEHIS HSL Forum 2021 Planning
  Develop agenda, solicit speakers, assist in logistics and marketing, and plan AEHIS HSL Forum 2021, taking place in Orlando, Fla. October 25-27.
- Joint Cybersecurity Working Group
  Several Initiatives will be coming forward in 2018 as a result of the HHS sponsored Joint CWG. The group will be focusing on tackling imperatives as a result of the Cybersecurity Task Force Report. As AEHIS continues to fortify its leadership role within HHS, we highly encourage members to participate in these initiatives, and look for your involvement.
- Medical Device Working Group
  Develop best practices associated with medical device cyber hygiene. In cooperation with CHIME and AEHIS public policy arms, promote developed best practices and work to advocate for improved pre- and post-market controls of medical devices.
- Certification Exploration
  Explore the feasibility and criteria for an AEHIS-sponsored certification or certificate program for CISOs and other healthcare information security leaders that can elevate the expertise of a healthcare specific CISO.

Personal Information

Organizational Information

Demographic Information

Additional Information