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Thank you for your interest and participation in Civitas Networks for Health. We appreciate you taking the time to thoroughly complete the information below to help us best understand your organization's structure, priorities, mission, and goals for participating in the network.

Whether you are looking to join Civitas as a new member, or are a longstanding member, we request that you answer all questions as thoroughly as possible. We will also request annual updates and all members must accept the terms and conditions and code of conduct, and contribute annual dues established by the Civitas Board of Directors.

The form uses logic and may prompt additional questions based on your selected response. If you have questions, please email contact@civitasforhealth.org.

Membership Status

Membership Type

Organizational Information
Please provide the following information for your organization.

Organization Name

Organization Description

Website

Street Address

City

State

Zip Code

Twitter Handle
Please insert your organization's Twitter handle so we can keep up with your news and achievements.

LinkedIn Page or URL Please insert your organization's LinkedIn page or URL so we can keep up with your news and achievements.

SB&T Partnership and Procurement Guide Would you like to be featured in our Partnership and Procurement guide?

YesNo

SB&T Partnership and Procurement Guide - Description Please provide a brief description of your services and any other pertinent information you would like us to include in our SB&T Partnership and Procurement Guide.

SB&T Partnership and Procurement Guide - Point of Contact and Title Please provide the name, title, and email of a point of contact whom you would like us to feature in our SB&T Partnership and Procurement Guide.

Logo
Please upload a high quality/vector logo for placement on our website and member area

President/Chief Executive Officer/Executive Director Contact

Please provide information for the organization's CEO/Executive Director and Executive Assistant, or related contact.

President/CEO/Executive Director First Name

President/CEO/Executive Director Last Name

President/CEO/Executive Director Job Title

President/CEO/Executive Director Email

Executive Assistant First Name

Executive Assistant Last Name

Executive Assistant Title

Executive Assistant Email

Will the President/CEO/Executive Director or Executive Assistant be the primary contact for any questions related to your membership?

Select Primary Contact

Primary Contact First Name

Primary Contact Last Name

Primary Contact Title

Primary Contact Email Address

Are any of the contacts listed above responsible for membership invoicing or other finance related questions?

Select Finance Contact Please select which contact should receive membership invoices and other finance related questions.

Finance Contact First Name

Finance Contact Last Name

Finance Contact Title

Finance Contact Email Address

Does your organization have a general accounting email?

If yes, please list the email here

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Community health centers	Government Representatives	Health plans/payers
Hospitals/health systems	Patients/patient advocates	Physicians/other providers
Public health	Purchasers/employers	Academic institutions

AK	AL	AR	AZ	CA
CO	CT	DE	DC	FL
GA	HI	IA	ID	IL
IN	KS	KY	LA	MA
MD	ME	MI	MN	MO
MS	MT	NC	ND	NE
NH	NJ	NM	NV	NY
OH	OK	OR	PA	RI
SC	SD	TN	TX	UT
VA	VT	WA	WI	WV
WY

Community Based Organization (CBO)	Health Center Controlled Network (HCCN)	Health Data Utility (HDU)
HIE	M/APCD	None
Pathways Community Hub	QIN/QIO	Qualified Entity (QE)
Regional Health Improvement Collaborative (RHIC)	Other

Data and Information Exchange	Data Science/Analytics
Education & Training	Evaluation
Information Security & Cybersecurity	Measure Development/Reporting
Program Technical Assistance	Public Health/Population Health
Quality Improvement	Research
Social Care Referrals and Connections

Organizational Information
Please provide the following information for your organization.

Organization Structure and Size
Please provide information on the structure and size of your organization.

Membership Terms and Conditions and Code of Conduct

AK	AL	AR	AZ	CA
CO	CT	DE	DC	FL
GA	HI	IA	ID	IL
IN	KS	KY	LA	MA
MD	ME	MI	MN	MO
MS	MT	NC	ND	NE
NH	NJ	NM	NV	NY
OH	OK	OR	PA	RI
SC	SD	TN	TX	UT
VA	VT	WA	WI	WV
WY

AK	AL	AR	AZ	CA
CO	CT	DE	DC	FL
GA	HI	IA	ID	IL
IN	KS	KY	LA	MA
MD	ME	MI	MN	MO
MS	MT	NC	ND	NE
NH	NJ	NM	NV	NY
OH	OK	OR	PA	RI
SC	SD	TN	TX	UT
VA	VT	WA	WI	WV
WY

Organizational InformationPlease provide the following information for your organization.

Organization Structure and SizePlease provide information on the structure and size of your organization.

Membership Terms and Conditions and Code of Conduct

Organizational Information
Please provide the following information for your organization.

Organization Structure and Size
Please provide information on the structure and size of your organization.

AK	AL	AR	AZ	CA
CO	CT	DE	DC	FL
GA	HI	IA	ID	IL
IN	KS	KY	LA	MA
MD	ME	MI	MN	MO
MS	MT	NC	ND	NE
NH	NJ	NM	NV	NY
OH	OK	OR	PA	RI
SC	SD	TN	TX	UT
VA	VT	WA	WI	WV
WY