International Membership Application

Full Name*
First Last
Designation
(i.e. PhD, CHCIO, FCHIME)
Email*
Organization Name*
Job description*
(or a brief statement that highlights your current job responsibilities)
Current organizational chart of your IT department that shows your position and those who report to you
IT Department Organizational Chart*
If you have one organizational chart that shows both the IT department and your direct reports, and to whom you report, you only need to submit the document once.
Current organizational chart showing where you fit into the organization as a whole and to whom you report.
Whole Organizational Chart
If you have one organizational chart that shows both the IT department and your direct reports, and to whom you report, you only need to submit the document once.

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Organization Demographics
Does your Organization participate in an Integrated Delivery System/Network?
- Yes
- No
Network/System Name:
Organization Type:
Please Specify
Hospital Type
Organization Ownership
- Non-Government Not-For-Profit
- Non-Government For Profit
- Government- Military
- Government- City, County, State
Is your Organization part of an ACO?
- Yes
- No
Name of ACO
Number of Organization Employees
Number of total IT staff in FTE's
Number of Outsourced IT staff
Number of Staffed Inpatient Beds
Primary EHR Vendor
Other significant Vendors Used
Privacy Policy*
- Check here to indicate that you have read and agree to the CHIME privacy policy terms.
Our Commitment To Privacy: Your privacy is important to us. To better protect your privacy we provide this notice explaining our online information practices and the choices you can make about the way your information is collected and used.

The Information We Collect: This notice applies to all information collected or submitted on the College of Healthcare Information Management Executives (CHIME) website. The types of personal information collected on these pages are (but not limited to):
- Name
- Title
- Employer
- Address
- Email address
- Phone number
- (Etc.)

On some pages, you can submit information about your organization. Types of organizational information collected are ( but not limited to):
- Structure
- Type
- Teaching Status
- Business Lin
- (Etc.)

The Way We Use Information: We use the information you provide about yourself and/or your organization only to 1) better identify and connect you with members (and them with you) whose organizations, demographics, and interests are similar in nature, and 2) better understand your professional needs and interests so that we may provide better customized services tailored to your individual preferences. We may use non-identifying and aggregate information to better design our website.

Finally, we never use or share the personally identifiable information provided to us online in ways unrelated to the ones described above without also providing you an opportunity to opt-out or otherwise prohibit such unrelated uses. As a practice, we do not share the information you provide with any outside parties.

Our Commitment To Data Security: To prevent unauthorized access, maintain data accuracy, and ensure the correct use of information, we have put in place appropriate physical, electronic, and managerial procedures to safeguard and secure the information we collect online.

How You Can Access Or Correct Your Information: Currently, you can access all your personally identifiable information that we collect online and maintain by calling our Membership Services department at 734.665.0000. We use this procedure to better safeguard your information.

You can correct factual errors in your personally identifiable information by sending us a request that credibly shows error. To protect your privacy and security, we will also take reasonable steps to verify your identity before granting access or making corrections.

How To Contact Us: Should you have other questions or concerns about these privacy policies, please call us at 734.665.0000 or send us an email to [email protected]
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Individual Demographics

Organization Demographics