HIMSS Corporate Membership Application

You must select either a HIMSS or mHIMSS membership or both in order to submit the form.

Membership Level and Duesclear

Diamond ($25,000)
Platinum ($14,000 for companies with annual revenues > $10 million)
Platinum ($8,500 for companies with annual revenues < $10 million)
Gold ($8,000 for companies with annual revenues > $10 million)
Gold ($3,500 for companies with annual revenues < $10 million)

Additional HIMSS Options

These options are only available when applying for HIMSS corporate membership.

Join the Diversity Business Roundtable (Minority, woman, or veteran-owned business - No additional fees apply)
Join the Medical Banking Project workgroups and activities, excluding G7 Membership

mHIMSS Corporate Membershipclear

5-Bar ($15,000)
5-Bar ($12,500 for HIMSS Diamond Corporate Members)
3-Bar ($6,500)
1-Bar ($1,500)

HIMSS Corporate Membership Primary Contactclearcopy corporate info

Salutation Mr. Ms. Mrs. Dr.
First Name
Middle Initial
Last Name
Email Address
Title
Mailing Address
City
State
Zip/Postal
Country
Contact Phone
Contact Fax Number

mHIMSS Corporate Membership Primary Contactclearcopy corporate info

Salutation Mr. Ms. Mrs. Dr.
First Name
Middle Initial
Last Name
Email Address
Title
Mailing Address
City
State
Zip/Postal
Country
Contact Phone
Contact Fax Number

Medical Banking Project Primary Contactclearcopy corporate info

Salutation Mr. Ms. Mrs. Dr.
First Name
Middle Initial
Last Name
Email Address
Title
Mailing Address
City
State
Zip/Postal
Country
Contact Phone
Contact Fax Number

Authorization

has agreed to join

for the 12 month period beginning
Month
Year

understands member benefits begin upon receipt of full payment.
If payment is not sent with the application, we authorize HIMSS to invoice our firm.

I understand that HIMSS may deposit the enclosed dues pending consideration of this application. In the event the application is not approved,
HIMSS will promptly refund my remittance.

Authorized by

HIMSS Corporate Membership Application

Corporate Information

Membership Level and Duesclear

Additional HIMSS Options

mHIMSS Corporate Membershipclear

HIMSS Corporate Membership Primary Contactclearcopy corporate info

mHIMSS Corporate Membership Primary Contactclearcopy corporate info

Medical Banking Project Primary Contactclearcopy corporate info

Payment

Authorization

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