AEHIT membership is open to CTOs and senior technology leaders at healthcare provider and payer organizations. The mission of AEHIT is to advance the role of the CTO through education, collaboration, and advocacy in support of the application of technology to improve healthcare safety and efficiency. If you are with a vendor organization, please find the AEHIT Foundation application here. Personal InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Designation Graduate Degree(s)Job Title*Birth Date MM DD YYYY Gender*MaleFemaleAssociation Membership(s) ACHE AHA AHIA AHIMA HFMA HIMSS IANS SANS Other Please SpecifyOrganizational InformationOrganization Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone Number*Alternate Phone NumberMobile Phone NumberPrimary Email* Enter Email Confirm Email Alternate Email Enter Email Confirm Email Organization's WebsiteTo whom do you report? (CEO, COO, etc.)What is the name of your organization's CIO?* First Last Demographic InformationWhat 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/ClinicBehavioral Health CareGroup Practice/ClinicHealth Insurer/Insurance OrganizationHospiceHospital/Acute Care FacilityIntegrated Delivery System/NetworkLaboratoryManaged CareMSONursing HomeSpecialty Hospital (Children, Cancer, Rehab, etc.)OtherPlease SpecifyNumber of staffed inpatient beds1-2525-99100-249250-399400-9991,000+Not ApplicableAdditional InformationHow did you hear about AEHIT? Would you be willing to speak to your peers about AEHIT?YesNoNot sureWould you be interested in participating in any of the following AEHIT committees?(Select all that apply) Education & EventsSolicit/schedule presenters for webinars, solicit best practices from membership, determine which are worthy of KnowledgeHub entry, and plan/execute AEHIT Fall Summit, scheduled for Oct 31 in San Antonio. Collaborative RelationshipsDetermine appropriate AEHIT partnerships–within and outside healthcare space; leverage these collaborative opportunities to mesh with Education/Professional Development/Public Policy efforts. AwardsDetermine criteria for CTO of the Year, solicit nominations, select winner, and present at Fall Summit.
