Thank you for your interest in attending the Healthcare IT Summit.

Please complete the registration form below. Please note: Due to limited available seats and minimum qualifications, your registration does not guarantee event participation.

Please contact Taylor Hyams at 508-416-1164 or taylor.hyams@ubm.com with any questions regarding the event.

•Required Information

First Name
Last Name
Professional Title
Organization Name
Street Address
City
State
Zip
Telephone
Cellphone
Fax
E-mail Address
Website
Do you have an Administrative Assistant
(to assist with arranging travel)?
Yes     No
If so, what is the Administrative Assistant's Name?
What is the Administrative Assistant's E-mail Address

1. Are you an Insurance Organization or a Healthcare Provider?
Insurer.     Healthcare Provider.

2. How would you best describe your organization?
Acute Care Facility Multi Hospital System
Group Purchasing Organization Single Hospital
Physicians Group Insurer
Government Organization

3. What level of involvement do you have in the decision making process when it comes to IT purchases?
Final Decision Maker IT Recommender
Influencer None

4. Approximately, how many lives does your organization insure?
Under 200,000 200,000 - 499,999
500,000 - 1,000,000 Over 1,000,000
N/A

4. How many beds does your hospital currently staff?
Less than 50 50 - 99
100 - 149 150 - 199
200 - 249 250 - 499
500 - 1000 More than 1000
N/A

5. What is your organizationís total annual revenue?
Less than $5 Million $5 Million - $49.9 Million
$50 Million - $99.9 Million $100 Million - $249.9 Million
$250 Million - $499.9 Million More than $500 Million
Non-Profit or Government Agency

6. What is your organization's approximate annual IT budget?
Less than $500,000 $500,000 - $999,999
$1 Million - $1.9 Million $2 Million - $4.9 Million
$5 Million - $9.9 Million $10 Million - $19.9 Million
$20 Million - $24.9 Million $25 Million - $49.9 Million
$50 Million - $99.9 Million $100 Million - $499.9 Million
$500 Million - $1 Billion Over $1 Billion

7. How many people are employed in entire organization?
1 - 99 100 - 499
500 - 999 1000 - 2499
2500 - 4999 5000 - 9999
More than 10,000

8. Please rate your organization's interest level on the following solutions and topics over the next 12-18 months.
High Medium Low
Ambulatory Care
Application Integration
Application Software
Business Intelligence
Business Process Management
Care Management
Clinical Systems
Cloud Computing
Compliance/Risk Management
Content Resource Management
Data Center
Data Protection
Data Retention
Desktop Virtualization
Disaster Recovery/Business Continuity
Electronic Medical Record / Electronic Health Record
Enterprise Resource Planning
Evidence Based Medicine
Hardware
Information Management
IT Infrastructure
IT Management
IT Services
Mobile Devices
Mobility
Managed Services/On-Demand Services
Networking
PPM / Project Management
Revenue Cycle Management
Regional Health Information Organizations
Security
Server Virtualization
Sharepoint
Social Media/Collaboration
Storage
Unified Communications
Wireless LAN







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