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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 organization.

Whether you are looking to join Civitas as a new member or are a longstanding member and are renewing your membership, 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.


Organizational Information
Please provide the following information for your organization.













Contact Information

  • President/CEO/Executive Director: The primary leader of the organization, responsible for overall strategic direction, decision-making, and organizational management.
  • Executive Assistant: Provides administrative and operational support to the President/CEO/Executive Director and the organization, ensuring smooth coordination of leadership tasks and initiatives.
  • Primary Contact: Serves as the main liaison for membership-related communications between the organization and the Civitas team, managing all inquiries, updates, and relevant information.
  • Finance Contact: Oversees financial transactions, including processing invoices and handling finance-related matters on behalf of the organization, ensuring timely and accurate financial management.

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




















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









Designation Definitions

  • CBO  – Community-based organization. Nonprofits serving those most in need and filling the gaps in traditional healthcare services, they are an essential part of the nation's public health system. 
  • CIE – Community Information Exchange. A community-governed infrastructure that enables information to be effectively and responsibly shared among many organizations, using different, interoperable technologies, in support of holistic coordination of care and equitable systems change.
  • CMMI Model Participant – The Center for Medicare and Medicaid Innovation (CMMI), also known as the “Innovation Center”. CMMI Model participants are official partners in active CMMI model programs.
  • Community Care Hub (CCH). Serves as a community-focused regional, statewide or multi-state umbrella organization that coordinates, centralizes and scales administrative functions and operational infrastructure on behalf of a network of community support providers. 
  • HDU – Health Data Utility. One or more entities serving a specific geography, guided by a diverse stakeholder governance structure, that combine, enhance, and exchange disparate electronic health data sets for treatment, care coordination, quality improvement, population health, public health emergencies, and other public and community health purposes. 
  • HIE – Health Information Exchange. Refers both to the process of securely sharing health-related data and the organizations that facilitate this exchange.
  • APCD – All-Payer Claims Databases. Large data warehouses that collect and maintain medical, pharmacy, and dental claims, along with eligibility and provider files from private and public payers. 
  • QE – Qualified Entity. The CMS QE Program (also known as the Medicare Data Sharing for Performance Measurement Program) enables organizations to receive Medicare claims data under Parts A, B, and D for use in evaluating provider performance.
  • QHIN – Qualified Health Information Network. Large health information networks that serve as the backbone for network connectivity across the country to support TEFCA exchange.
  • QIN/QIO – Quality Innovation Network/Quality Information Organization. The QIO program is led by the Centers for Medicare & Medicaid Services (CMS). QIN-QIOs assist patients and families, healthcare professionals, and communities.
  • RHIC – Regional Health Improvement Collaboratives. RHIC’s are a collaborative coalition of organizations dedicated to improving healthcare. RHICs are nonprofit organizations governed by multi-stakeholder boards that include consumers, healthcare providers, payers, and purchasers of healthcare. 




Expertise and Strategic Priorities

In order to best serve our members, it is important that we understand your organizational areas of expertise and strategic priorities. We also recognize that priorities change and will request updates annually.













Membership Terms and Conditions and Code of Conduct


Civitas prides itself on delivering benefits that provide members an opportunity to engage, network, and collaborate. To support opportunities for safe and open discussion, all members must adhere to Membership Terms and Conditions and Code of Conduct.

Terms and Conditions and Code of Conduct*
By submitting this form and completing the signature page, I am acknowledging that I am an authorized representative of my organization to review and accept the Membership Terms and Conditions and Code of Conduct for Civitas Networks for Health.




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