NOTE:The length of this application varies based on the type of membership you're seeking. The form does NOT allow you to save it before submitting, so please gather all the information you need before beginning. Select the type of membership from below to see all the fields that will need to be completed. Type of Membership*Full MemberAffiliate MemberPlease select the type of membership you wish to apply for. More questions will appear below after you select a type of membership, and the questions you will see will depend on the type of membership you are seeking. Membership Description Membership in the Network for Regional Healthcare Improvement (NRHI) is open to Regional Health Improvement Collaboratives (RHICs) that meet the criteria established by the NRHI Board of Directors. To qualify for full NRHI membership, an organization must meet the following requirements. The organization must be a Regional Health Improvement Collaborative, defined as: A non-profit organization; Which is working to improve healthcare quality and value through an active program of quality measurement and public reporting or an active program of quality improvement, or both; In a specific geographic region of the country (typically either a metropolitan region or state); Through a collaborative effort of healthcare providers and other stakeholders. The organization must have representation from four types of stakeholders on its governing board: Healthcare providers (hospitals, physician groups, physicians, home health agencies, nursing homes, clinics, etc.); Healthcare purchasers (employers who purchase health insurance for their employees, state Medicaid agencies who contract with health plans for care, etc.); Healthcare payers (private health insurance plans, state Medicaid agencies that directly pay for care, etc.); and Healthcare consumers or consumer organizations. An organization that meets the criteria above may apply for full NRHI membership by submitting a membership application, a signed letter of recommendation from an NRHI member RHIC operating in your state (or a letter from an NRHI member RHIC in another nearby region if there are currently no NRHI members in your state), signing the NRHI Conflict of Interest policy, and abiding by NRHI Guiding Principles. A Full Member shall contribute annual dues (which vary based on the size of organization) established by the NRHI Board of Directors and shall have the rights and benefits of full membership. Membership Description Organizations that do not qualify for full membership in NRHI may apply to become an Affiliate Member. To qualify as an Affiliate Member an organization must meet the following eligibility requirements: Be committed to improving health and health care in the US through multi stakeholder collaboration. Be a national/regional/state partner (examples include but are not limited to vendors, philanthropies, employers, industry or trade association, local or state/federal governments). An entity that meets the criteria above may elect to join NRHI as an Affiliate Member by submitting this application, signing NRHI’s Conflict of Interest policy, and abiding by NRHI Guiding Principles.Organization InformationOrganization Name*Address* Street Suite City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Contact Name* First Last Phone*Email* Tax Status*Please indicate your corporate and IRS tax status:Non-profit 501(c)(3)Non-profit 501(c) status other than 501(c)(3)Revenue*Please select your organization's annual revenue:Less than $1.75 millionBetween $1.75 and $5 millionMore than $5 millionGeographic Reach*Please describe the area your organization supports.Description and Goals*Provide a brief description of your entity, including your vested interest and role in improving health and health care in the US. Why do you want to become an NRHI member?*Date of application submission*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Upon confirming your submission, you will be redirected to a short form that will ask you a few questions about your organization's strategic goals. Your responses will help inform NRHI strategic member programming and funding opportunities. Your application will be complete upon submitting your replies to the form. Thank you!Application Requirement: GovernanceUpload Bylaws*Please attach a copy of the relevant section of your corporate or organizational bylaws describing the requirements for composition of your governing body. Drop files here or Accepted file types: pdf, doc. Current Members*Please attach a list of the current members of your governing body. Drop files here or Accepted file types: pdf, doc, xls. Letter of RecommendationA signed letter of recommendation from an NRHI full-member RHIC operating in your state or a letter from an NRHI full-member RHIC in another nearby region if there are currently no NRHI members in your state. If you are still expecting to receive the letter of recommendation at the time of your application submission, please, indicate this in a note at the end of the form. Drop files here or Accepted file types: pdf, doc. Conflict of Interest*Attach a signed copy of NRHI's Conflict of Interest policy. Click here to open and download the file, then upload it here once it has been completed. Drop files here or Accepted file types: pdf. Additional Supporting DocumentationRelevant supporting documentation if applicable. Drop files here or Accepted file types: pdf, doc, xls. Please describe the current members of your governing body. How many members of the governing body are:Practicing PhysiciansNumber of practicing physiciansNon-practicing PhysiciansNumber of individuals employed by or representing physicians or physician practices, but not practicing physicians:Hospital RepresentativesNumber of individuals employed by or representing hospitals:Private PurchasersNumber of individuals employed by or representing private (non-healthcare provider) purchasers (i.e., private businesses that do not deliver healthcare services or manufacture healthcare products or medications, and that offer health insurance to their employees):Public PurchasersNumber of individuals employed by or representing public purchasers (i.e., government agencies that purchase health insurance for the government's employees or state Medicaid agencies):Healthcare ConsumersNumber of healthcare consumers (individuals who do not meet the criteria for any of the above categories and whose presence is intended to represent consumer and patient interests):OtherNumber of others (that do not fit any previous category):If other, please explain:TOTAL NUMBER OF MEMBERS*Please add up the total number of members and enter it here.Application Requirement: ProgrammingMeasurement and Reporting*Do you have a program for quality/cost measurement and reporting?We have an active program.We have an active program of measurement, but we do not do public reporting at this time.We do not have and are not currently planning to have a program for measurement and reporting of quality or cost measures.We are planning a program for measurement and reporting.We expect it to be operational by:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Quality/Cost Measurement*Please include a brief description of your quality/cost measurement and reporting programming: Quality and Cost Reduction*Do you have an active program for improving quality and/or reducing costs of healthcare services in the community you serve (other than measuring and reporting on quality and costs)?Do you have an active program for improving quality and/or reducing costs of healthcare services in the community you serve (other than measuring and reporting on quality and costs)?We do not have and are not currently planning to have a program for improving quality or reducing costs of healthcare services other than measurement and reporting.We are planning a program.We expect it to be operational by:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Complete ApplicationCompleted Application Checklist* A copy of the relevant section of your corporate or organizational bylaws describing the requirements for composition of your governing body. A signed letter of recommendation from an NRHI full-member RHIC now operating in your state (or a letter from an NRHI full-member RHIC in another nearby region if there are currently no NRHI members in your state). A signed NRHI Conflict of Interest policy. A list of the current members of your governing body. Relevant supporting documentation if applicable. I am missing 1 or more of the required attachments. (Explain below.) I have included the following attachments to complete my application:Missing Information Explanation*If any documentation is missing, please explain why here:Date of application submission*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHA Upon confirming your submission, you will be redirected to a short form that will ask you a few questions about your organization's strategic goals. Your responses will help inform NRHI strategic member programming and funding opportunities. Your application will be complete upon submitting your replies to the form. Thank you!PhoneThis field is for validation purposes and should be left unchanged.