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State/ Province *

Select...AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Minor Outlying IslandsUtahVermontVirgin Islands of the U.S.VirginiaWashingtonWest VirginiaWisconsinWyomingOthers

Phone Number *

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Business Email *

Which of the following best describes your primary job function?

Hospital Administrators Heads of Departments Corporate Management Communications/Network management Software/Product Development Marketing/Sales Other (please specify)

How many people are employed in your entire organization including all branches, divisions, and subsidiaries? (Select one only) *

Total Employees in your entire organization 1. Over 40,000 2. 30,001 - 40,000 3. 20,001 - 30,000 4. 10,001 - 20,000 5. 5,001 - 10,000 6. 1,001 - 5,000 7. 501 - 1,000 8. 100-500 9. Less than 100

Which of the following best describes your organization's industry or function? (Select one only) *

Please select an industry..... 1. Hospital 2. Multi-Hospital 3. Integrated Delivery System 4. Healthcare Consulting Firm 5. Federal, State or Local Government 6. Insurance: Payer or Company) 7. Managed Care 8. Life Sciences 9. Public Health 10. Community Health-center Clinic 11. Home Healthcare Organizations 12. Biotechnology 13. Pharmaceuticals

If your industry is "Other" please specify:*

What is the total revenue of your organization? (Select one only) *

Total annual revenues of entire organization 1. Over $40 Billion 2. $30 Billion to $39.9 Billion 3. $15 Billion to $29.9 Billion 4. $10 Billion to $14.9 Billion 5. $5 Billion to $9.9 Billion 6. $1 to $4.9 Billion 7. $501 to $999 Million 8. $101 to $500 Million 9. $50 to $100 Million 10. Under $50 Million

Which of the following products, services and / or technologies do you currently or plan to approve, specify, recommend, purchase or influence the purchase of? (Check all that apply) *

• Population Health Management
• Healthcare Document Management
• Healthcare Communication
• Telemedicine Solutions
• Patient Monitoring Solutions
• EMR/EHR Solutions
• Healthcare Analytics Solutions
• Medical Imaging
• Healthcare Information Exchange Solutions
• Healthcare Compliance
• Healthcare Revenue Cycle Management Solutions
• Practice Management

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