SHIEC Associate Member Application Instructions:

  1. Complete this application by including your senior leadership contact information and your website URL.
  2. Include a brief description of your organization. This information will be circulated to the SHIEC Board.
  3. The SHIEC Board will review your application and determine your eligibility to join.
  4. You will be notified of the Board’s decision or contacted for additional information if necessary.


Senior Leadership Contact Information:

Person Completing this form, if different from above:

Organization Type


FederalStateLocalAre you a State Designated Entity?

Hospitals/Health SystemsHealth Plans/PayersPublic HealthCommunity Health CentersPhysicians/Other ProvidersConsumers/PatientsEmployersGovernmentalOther

(Please describe your HIE’s service area. List approximately how many unique patients are in your MPI.)

1 Year ($6,000)2 Year ($11,000)