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Membership Application

Please complete this form for both new and renewing members for the 2011-12 membership year. After we received your form, our membership committee will review and once approved, we will be sending a confirming email with a new member password. If you have any questions, please contact our PAeHI office at admin@paehi.org or leave a message at 717-561-5338.

Thank you for your patience with our new process.

GENERAL INFORMATION
If you are applying as an individual, enter your name in the Organization Name space.

* Organization Name:

* Mailing Address:

* City:

* State:

* Zip Code:

* County:

* Company Phone (include area code):

* Website:

MAIN REPRESENTATIVE (Voting Member)

* Full Name (First, Last):

* Title:

* Phone (include area code & extension):

Fax (include area code):

* Email:

ORGANIZATION MEMBERSHIP - Representatives and Committee Selection
Each organization can have up to five additional representatives' names added to the database. Please indicate what committee these representatives would like to serve on from the following committees list: (1) Business Analysis and Technology (BAT); (2) Communication and Education (C&E); (3) Finance; (4) Membership; (5) Policy; (6) Health Information Exchange (HIE).

Representative 1

Full Name (First, Last):

Title:

Phone (include area code & extension):

Fax (include area code):

Email:

Committee of Choice:

Representative 2

Full Name (First, Last):

Title:

Phone (include area code & extension):

Fax (include area code):

Email:

Committee of Choice:

Representative 3

Full Name (First, Last):

Title:

Phone (include area code & extension):

Fax (include area code):

Email:

Committee of Choice:

Representative 4

Full Name (First, Last):

Title:

Phone (include area code & extension):

Fax (include area code):

Email:

Committee of Choice:

Representative 5

Full Name (First, Last):

Title:

Phone (include area code & extension):

Fax (include area code):

Email:

Committee of Choice:

MEMBERSHIP DUES SCHEDULE

Select the membership class from the drop down below.

* Membership Class:

Hospitals and Hospital Organizations:

Clinician and Clinician Organizations - Licensed Revenue / Producing Clinician / FTEs:

Insurance Organizations - Member Lives:

Government Organizations - Fixed Fee:

Professional Health Care Organizations - Gross Annual Revenue:

Quality Improvement Organizations - Gross Annual Revenue:

Business / Purchaser Organizations - Gross Annual Revenue:

Supporting Member Organizations - Gross Annual Revenue:

Consumer / Public Interest / At-Large Organizations - Fixed Rate:

By Submitting this form, I hereby certify that the above information is accurate and complete. I (organization or individual) am committed to the mission and purposes of the Pennsylvania eHealth Initiative and agree to abide by its bylaws when participati

Membership Application

MEMBERSHIP DUES SCHEDULE

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