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
*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
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
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
*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. Annual Meeting Seminar/Workshop Audio Conference/Webinar No Preference
To select more than one: While holding the Ctrl key, click on your selections below.
Annual Meeting Seminar/Workshop Audio Conference/Webinar No Preference
*Preferred Speaking Time of Day
Morning Afternoon No preference
Preferred Associations
Select one or more healthcare associations that you would like to apply to speak. Florida Health Information Management Association (FHIMA) Georgia Health Information Management Association (GHIMA) Healthcare Quality Professionals of New Jersey (HQPNJ) 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) Pennsylvania Health Information Management Association (PHIMA) Tennessee Health Information Management Association (THIMA) Texas Health Information Management Association (TxHIMA) West Virginia Health Information Management Association (WvHIMA) Wyoming Health Information Management Association (WyHIMA)
Select one or more healthcare associations that you would like to apply to speak.
Florida Health Information Management Association (FHIMA) Georgia Health Information Management Association (GHIMA) Healthcare Quality Professionals of New Jersey (HQPNJ) 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) Pennsylvania Health Information Management Association (PHIMA) Tennessee Health Information Management Association (THIMA) Texas Health Information Management Association (TxHIMA) West Virginia Health Information Management Association (WvHIMA) 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
Additional Speakers
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
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. 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.
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
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.
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