Home > Membership > HIE Apply
  1. Complete this application by including your senior leadership contact information and your website URL.
  2. Include a brief description of your HIE. 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.

    Organization Information

    Senior Leadership Contact Information:

    Person Completing this form, if different from above:

    Organization Type




    FederalStateLocalAre you a State Designated Entity?

    Stakeholders Represented on HIE Board

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

    Organization Size

    Requested Membership

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