Speaker Bureau Submission Form

Association That You Wish To Speak*

All

Alabama Health Information Management Association (aahim.org)

Alaska Health Information Management Association (akhima.org)

Arizona Health Information Management Association (azhima.org)

Arkansas Health Information Management Association (arhima.org)

California Cancer Registrars Association (ccraregistrars.org)

Cancer Registrars Association of New England (craneweb.org)

Chicago Area HIMA

Colorado Health Information Management Association (chima.org)

Dallas Fort Worth Health Information Management (dfwhima.org)

Delaware Health Information Management (dehima.org)

Florida Health Information Management Association (fhima.org)

Georgia Health Information Management Association (ghima.org)

Health Information Management Association of New York City (himanyc.org)

Houston Area Health Information Management Association (hahima.org)

Idaho Health Information Management Association (idhima.org)

Illinois Health Information Management Association (ilhima.org)

Indiana Security and Privacy Network (inspn.org)

Iowa Health Information Management Association (iahima.org)

Kansas Health Information Management Association

Kentucky Health Information Management Association (khima.org)

Knoxville Health Information Management Association

Louisiana Health Information Management Association (lhima.org)

Memphis Health Information Management Association

Michigan Health Information Management Association (mhima.org)

Michigan Cancer Registrars Association (miregistrars.org)

Maine Health Information Management Association (mehima.org)

Maryland Health Information Management Association (mdhima.org)

Minnesota Health Information Management Association (mnhima.org)

Missouri Health Information Management Association (mohima.org)

Montana Health Information Management Association (montanahima.net)

Nebraska Health Information Management Association (nhima.org)

Nevada Health Information Management Association (nvhima.org)

New Mexico Health Information Management Association (nmhima.org)

North Carolina Health Information Management Association (nchima.org)

North Dakota Health Information Management Association (ndhima.org)

Oklahoma Health Information Management Association (okhima.org)

Oncology Registrars Association of New Jersey (oranjonline.com)

Oregon Health Information Management Association (orhima.org)

Ozark Area Health Information Management Association

Pennsylvania Association of Cancer Registrars (pacr.org)

Pennsylvania Health Information Management Association (phima.org)

South Carolina Health Information Management Association (schima.org)

South Dakota Health Information Management Association (sdhima.org)

Southeastern Pennsylvania Health Information Management Association (sephima.org)

Tennessee Health Information Management Association (thima.org)

Texas Health Information Management Association (txhima.org)

Texas Oncology Data Association (txoda.org)

The Carolinas Summit

Tidewater Region — VHIMA (vhima.org/tidewater-region)

Twin State Health Information Management Association (tshima.org)

Utah Health Information Management Association (uhima.org)

Virginia Health Information Management Association (vhima.org)

Washington State Health Information Management Association (wshima.org)

Washington State Tumor Registrars Association (wstra.net)

West Virginia Health Information Management Association (wvhima.org)

Western Tennessee Health Information Management Association

Wisconsin Health Information Management Association (whima.org)

Wyoming Health Information Management Association (wyhima.org)

OtherOther

First Name*

Last Name*

Credentials

Title

Employer

Address*

City*

State*

Zipcode*

Email Address*

Work Phone*

Cell Phone

Website

Names and email addresses of co-presenters

Brief Bio(s) (Max 100 words)*

0 of 100 max words

Presenter's Photograph (to be used by Associations as part of the Speaker Bio)

Maximum file size: 2MB

Co-Presenter Photograph (to be used by Associations as part of the Speaker Bio)

Maximum file size: 2MB

About the Presentation

Meeting Type*

Annual Meeting

In-Person (Meeting)

Virtual (Webinar)

Presentation Title*

Presentation Description*

Learning Objectives

List any organizations that have heard your presentation and include the contact person for that organization, along with phone and email.

Topic Areas Descriptions

Audio Visual Equipment

Fees

Speaking Fee*

No Charge

Honorarium Requested

My Company is Sponsoring

Honorarium Fee

Travel Fees

Other Fees

Conflict of Interest Disclosure

Please describe below any relationships, transactions, positions you hold (as owner, director, or volunteer for a for-profit or nonprofit organization,) or circumstances that you believe could contribute to an actual or perceived conflict of interest between the XYZ organization, Inc., and your personal interest — financial, dual loyalty or otherwise.

Today's date: 09/14/2026

Name

coi lname

Title/Position

Conflicts

I (or my spouse/life partner) sit on the following nonprofit board(s).

I (or members of my family as specified in the XYZ Organization, Inc. Conflict of Interest Policy) am/are an owner, officer, director, or a majority shareholder of the following for-profit business(es).

List the nonprofit boards.

List the for profit businesses.

Comments or Questions

Comments/Questions

Speaker Agreement

Click here to review the speaker agreement.

I agree and accept the speaker agreement terms*

I agree and accept

Captcha

Speaker Bureau Submission Form

About the Presentation

Audio Visual Equipment

Fees

Conflict of Interest Disclosure

Comments or Questions

Speaker Agreement

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