AEHIS membership is open to CISOs and senior security leaders at healthcare provider and payer organizations. The mission of AEHIS is to advance the role of the CISO through education, collaboration, and advocacy in support of secure health information for the protection of both healthcare organizations and consumers. If you are with a vendor organization, please find the AEHIS 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'IvoireCroatiaCubaCuraçaoCyprusCzech 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?* 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/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 AEHIS?Would you be willing to speak to your peers about AEHIS?YesNoNot sureWould you be interested in participating in any of the following AEHIS 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 AEHIS Fall Summit, scheduled for Oct 31 in San Antonio. Professional Development Develop strategies for CISO professional growth; determine feasibility/criteria for an AEHIS-sponsored certification. Collaborative RelationshipsDetermine appropriate AEHIS partnerships–within and outside healthcare space; leverage these collaborative opportunities to mesh with Education/Professional Development/Public Policy efforts. AwardsDetermine criteria for CISO of the Year, solicit nominations, select winner, and present at Fall Summit.
