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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Best Phone Number to Reach You*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) Professional Development & EducationSolicit and schedule presenters for webinars, podcasts, and other AEHIS media events. Solicit and review KnowledgeHub submissions and best practices. Fall Summit PlanningDevelop agenda, solicit speakers, assist in logistics and marketing, and plan the annual AEHIS Fall Summit, taking place in San Diego, CA from October 31 – November 2. 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.