Speaker Bureau Submission Form This Speaker Bureau Submission Form is a centralized online submission platform that is shared among numerous professional healthcare associations who are all seeking qualified, professional, knowledgeable speakers to share information with their members for purposes of continuing education. By completing the online form below, you can let one or more of these associations know that you are interested in conducting a presentation either face-to-face (traditional meeting) or virtual (audio conference/webinar) meeting. If you have any questions, please contact us by email or call 888.391.0977.
Speaker Bureau Submission Form
This Speaker Bureau Submission Form is a centralized online submission platform that is shared among numerous professional healthcare associations who are all seeking qualified, professional, knowledgeable speakers to share information with their members for purposes of continuing education.
By completing the online form below, you can let one or more of these associations know that you are interested in conducting a presentation either face-to-face (traditional meeting) or virtual (audio conference/webinar) meeting.
If you have any questions, please contact us by email or call 888.391.0977.
Instructions: Please complete the online application for each presentation title. * required information About You *First Name *Last Name Credentials Employer Title *Address Address *City *State Select One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Vigin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon International *Zip *Work Phone Cell Phone *Email Website *Bio This is a brief narrative biography for each presenter. It will be used to introduce the presenter(s) during the presentation, and may be included in marketing materials. Photo - please email a photo (optional).
Instructions: Please complete the online application for each presentation title.
* required information
About You
*First Name
*Last Name
Credentials
Employer
Title
*Address
Address
*City
*State
*Zip
*Work Phone
Cell Phone
*Email
Website
*Bio
This is a brief narrative biography for each presenter. It will be used to introduce the presenter(s) during the presentation, and may be included in marketing materials.
Photo - please email a photo (optional).
About Your Presentation
*Title
*Topic Area To select more than one: While holding the Ctrl key, click on your selections below. Behavioral Health Clinical Documentation Improvement Coding Compliance Data Management and Analysis eHIM Best Practices EHR Implementation and Planning Health Information Exchange HIM and the Law Legal Health Record Legislative and Advocacy Long-Term Care Management and Development Performance Improvement Personal Health Records/PHI Management Physician Practice Privacy and Security Project/Change Management Revenue Cycle Management Technology Other
*Topic Area
To select more than one: While holding the Ctrl key, click on your selections below. Behavioral Health Clinical Documentation Improvement Coding Compliance Data Management and Analysis eHIM Best Practices EHR Implementation and Planning Health Information Exchange HIM and the Law Legal Health Record Legislative and Advocacy Long-Term Care Management and Development Performance Improvement Personal Health Records/PHI Management Physician Practice Privacy and Security Project/Change Management Revenue Cycle Management Technology Other
To select more than one: While holding the Ctrl key, click on your selections below.
Behavioral Health Clinical Documentation Improvement Coding Compliance Data Management and Analysis eHIM Best Practices EHR Implementation and Planning Health Information Exchange HIM and the Law Legal Health Record Legislative and Advocacy Long-Term Care Management and Development Performance Improvement Personal Health Records/PHI Management Physician Practice Privacy and Security Project/Change Management Revenue Cycle Management Technology Other
*Description This is a brief 25-50 word description of presentation. This description will be used in the marketing material.
*Description
This is a brief 25-50 word description of presentation. This description will be used in the marketing material.
*Preferred Presentation Setting To select more than one: While holding the Ctrl key, click on your selections below. No Preference Annual Meeting Seminar/Workshop Audio Conference/Webinar
*Preferred Presentation Setting
To select more than one: While holding the Ctrl key, click on your selections below. No Preference Annual Meeting Seminar/Workshop Audio Conference/Webinar
No Preference Annual Meeting Seminar/Workshop Audio Conference/Webinar
*Preferred Speaking Time of Day To select more than one: While holding the Ctrl key, click on your selections below. No Preference Morning Afternoon Morning and Afternoon
*Preferred Speaking Time of Day
No Preference Morning Afternoon Morning and Afternoon
Preferred Associations Select one or more healthcare associations that you would like to apply to speak. To select more than one: While holding the Ctrl key, click on your selections below. Alabama Health Information Management Association Alamo Area Health Information Management Association (AAHIMA) Alaska Health Information Management Association (AKHIMA) Cancer Registrars Association of New England (CRANE) Central Pennsylvania Health Information Management Association (CPHIMA) Florida Health Information Management Association (FHIMA) Georgia Health Information Management Association (GHIMA) Healthcare Quality Professionals of New Jersey (HQPNJ) Health Information Management Association of New York City (HIMANYC) Iowa Health Information Management Association (IAHIMA) Lehigh Valley Health Information Management Association (LVHIMA) Maine Health Information Management Association (MEHIMA) Maryland Health Information Management Association (MDHIMA) Missouri Health Information Management Association (MOHIMA) New Jersey Health Information Management Association (NJHIMA) Northeastern Pennsylvania Health Information Management Association (NEPHIMA) Pennsylvania Association of Cancer Registrars (PACR) Pennsylvania Health Information Management Association (PHIMA) Southeastern Pennsylvania Health Information Management Association (SEPHIMA) Tennessee Health Information Management Association (THIMA) Texas Health Information Management Association (TXHIMA) West Virginia Health Information Management Association (WVHIMA) Western Pennsylvania Health Information Management Association (WPHIMA) Wyoming Health Information Management Association (WYHIMA)
Preferred Associations
Select one or more healthcare associations that you would like to apply to speak. To select more than one: While holding the Ctrl key, click on your selections below. Alabama Health Information Management Association Alamo Area Health Information Management Association (AAHIMA) Alaska Health Information Management Association (AKHIMA) Cancer Registrars Association of New England (CRANE) Central Pennsylvania Health Information Management Association (CPHIMA) Florida Health Information Management Association (FHIMA) Georgia Health Information Management Association (GHIMA) Healthcare Quality Professionals of New Jersey (HQPNJ) Health Information Management Association of New York City (HIMANYC) Iowa Health Information Management Association (IAHIMA) Lehigh Valley Health Information Management Association (LVHIMA) Maine Health Information Management Association (MEHIMA) Maryland Health Information Management Association (MDHIMA) Missouri Health Information Management Association (MOHIMA) New Jersey Health Information Management Association (NJHIMA) Northeastern Pennsylvania Health Information Management Association (NEPHIMA) Pennsylvania Association of Cancer Registrars (PACR) Pennsylvania Health Information Management Association (PHIMA) Southeastern Pennsylvania Health Information Management Association (SEPHIMA) Tennessee Health Information Management Association (THIMA) Texas Health Information Management Association (TXHIMA) West Virginia Health Information Management Association (WVHIMA) Western Pennsylvania Health Information Management Association (WPHIMA) Wyoming Health Information Management Association (WYHIMA)
Select one or more healthcare associations that you would like to apply to speak.
Alabama Health Information Management Association Alamo Area Health Information Management Association (AAHIMA) Alaska Health Information Management Association (AKHIMA) Cancer Registrars Association of New England (CRANE) Central Pennsylvania Health Information Management Association (CPHIMA) Florida Health Information Management Association (FHIMA) Georgia Health Information Management Association (GHIMA) Healthcare Quality Professionals of New Jersey (HQPNJ) Health Information Management Association of New York City (HIMANYC) Iowa Health Information Management Association (IAHIMA) Lehigh Valley Health Information Management Association (LVHIMA) Maine Health Information Management Association (MEHIMA) Maryland Health Information Management Association (MDHIMA) Missouri Health Information Management Association (MOHIMA) New Jersey Health Information Management Association (NJHIMA) Northeastern Pennsylvania Health Information Management Association (NEPHIMA) Pennsylvania Association of Cancer Registrars (PACR) Pennsylvania Health Information Management Association (PHIMA) Southeastern Pennsylvania Health Information Management Association (SEPHIMA) Tennessee Health Information Management Association (THIMA) Texas Health Information Management Association (TXHIMA) West Virginia Health Information Management Association (WVHIMA) Western Pennsylvania Health Information Management Association (WPHIMA) Wyoming Health Information Management Association (WYHIMA)
*Length of Presentation To select more than one: While holding the Ctrl key, click on your selections below. Half Hour Hour Hour and a Half 2 Hours 3 Hours 4 Hours All Day
*Length of Presentation
To select more than one: While holding the Ctrl key, click on your selections below. Half Hour Hour Hour and a Half 2 Hours 3 Hours 4 Hours All Day
Additional Speakers
Speaker First Name Last Name Email #2 #3 #4 #5
Fees Please indicate your fees below. The determination of compensation will be decided by the applicable association. *Speaking Fee To select more than one: While holding the Ctrl key, click on your selections below. No Charge Honorarium Requested My Company Is Sponsoring My Honorarium Fee Is: $ Other Fees: $ *Travel To select more than one: While holding the Ctrl key, click on your selections below. No Charge Airline Car Rental Hotel Meals Mileage Total Travel Fee: $
Fees
Please indicate your fees below. The determination of compensation will be decided by the applicable association.
*Speaking Fee
To select more than one: While holding the Ctrl key, click on your selections below. No Charge Honorarium Requested My Company Is Sponsoring
My Honorarium Fee Is: $ Other Fees: $
*Travel
No Charge Airline Car Rental Hotel Meals Mileage
Total Travel Fee: $
Audio Visual Equipment The association will provide an LCD projector and a microphone. The speaker must provide his/her own laptop. Please indicate any additional AV requests that you may have. However, the fulfillment of the request is not guaranteed and will be determined by the applicable association. To select more than one: While holding the Ctrl key, click on your selections below. Podium microphone Lapel microphone Standing microphone in aisle Wireless handheld microphone Sound from laptop to room speakers Internet access
Audio Visual Equipment
The association will provide an LCD projector and a microphone. The speaker must provide his/her own laptop. Please indicate any additional AV requests that you may have. However, the fulfillment of the request is not guaranteed and will be determined by the applicable association. To select more than one: While holding the Ctrl key, click on your selections below. Podium microphone Lapel microphone Standing microphone in aisle Wireless handheld microphone Sound from laptop to room speakers Internet access
The association will provide an LCD projector and a microphone.
The speaker must provide his/her own laptop.
Please indicate any additional AV requests that you may have. However, the fulfillment of the request is not guaranteed and will be determined by the applicable association.
Podium microphone Lapel microphone Standing microphone in aisle Wireless handheld microphone Sound from laptop to room speakers Internet access
Handouts All speakers should prepare a handout for their presentation. Handouts must be submitted to the association by the date instructed and should be in electronic format. If the speaker is unable to submit the handouts by the deadline date, he/she may be responsible informing the association and for the reproduction, shipping, and costs associated with making the handouts available. Please note that the association does not assume financial responsibility for development of the presentation. The length should not exceed 45 slides or 15 pages per hour of program content. Do not use more than 8 lines of text on each PowerPoint slide so they can be read when printed. Provide both the original PowerPoint file (ppt) and/or Microsoft Word document. All handouts must be converted to Acrobat Reader (PDF) documents. To download a free PDF converter, visit www.primopdf.com and download PrimoPDF For PowerPoint presentations, the Acrobat Reader (PDF) document should be printed in pure black and white in the handouts view with 3 slides per page with notes (learn more). Please review your slides to confirm that your handouts can be read in the 3-per-page handout format. Do not include advertisements for the speaker's organization or business, products or services.
Handouts
All speakers should prepare a handout for their presentation. Handouts must be submitted to the association by the date instructed and should be in electronic format. If the speaker is unable to submit the handouts by the deadline date, he/she may be responsible informing the association and for the reproduction, shipping, and costs associated with making the handouts available. Please note that the association does not assume financial responsibility for development of the presentation. The length should not exceed 45 slides or 15 pages per hour of program content. Do not use more than 8 lines of text on each PowerPoint slide so they can be read when printed. Provide both the original PowerPoint file (ppt) and/or Microsoft Word document. All handouts must be converted to Acrobat Reader (PDF) documents. To download a free PDF converter, visit www.primopdf.com and download PrimoPDF For PowerPoint presentations, the Acrobat Reader (PDF) document should be printed in pure black and white in the handouts view with 3 slides per page with notes (learn more). Please review your slides to confirm that your handouts can be read in the 3-per-page handout format. Do not include advertisements for the speaker's organization or business, products or services.
All speakers should prepare a handout for their presentation. Handouts must be submitted to the association by the date instructed and should be in electronic format.
If the speaker is unable to submit the handouts by the deadline date, he/she may be responsible informing the association and for the reproduction, shipping, and costs associated with making the handouts available. Please note that the association does not assume financial responsibility for development of the presentation.
The length should not exceed 45 slides or 15 pages per hour of program content. Do not use more than 8 lines of text on each PowerPoint slide so they can be read when printed. Provide both the original PowerPoint file (ppt) and/or Microsoft Word document.
All handouts must be converted to Acrobat Reader (PDF) documents. To download a free PDF converter, visit www.primopdf.com and download PrimoPDF
For PowerPoint presentations, the Acrobat Reader (PDF) document should be printed in pure black and white in the handouts view with 3 slides per page with notes (learn more). Please review your slides to confirm that your handouts can be read in the 3-per-page handout format.
Do not include advertisements for the speaker's organization or business, products or services.
Speaker Agreement I have reviewed and acknowledge acceptance of the Speaker Agreement. * Select One I agree
Speaker Agreement
I have reviewed and acknowledge acceptance of the Speaker Agreement. * Select One I agree
I have reviewed and acknowledge acceptance of the Speaker Agreement.
* Select One I agree
Comments Please let us know if you have any questions or comments.
Comments
Please let us know if you have any questions or comments.
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