Human Health Facility Licensee Application Form

Organizational Information

Company Name*

Contact Person*

First Last

Title

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone*

Fax*

Email*

What is your organization’s primary business?*

Shipping Information

Please complete the following if shipping information is different from company information provided above.

Same as above

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Telephone

Fax

Media Specifications

Media Preference - CD-ROM

Layout*

ASCII Comma-Delimited
ASCII Fixed Block

Application Categories & Fees ***

Entire HIN Database - Initial Access Fee

Price: $7,500.00 Quantity:

(Includes all Human Health records, on-going maintenance to records and access to iHIN.)

Annual License Fee is $4,000*

Weekly Updates*

Price: $800.00

((HIN licensees receive quarterly refreshes of the entire database, as well as access to the online portal.)

First Quarter Weekly Updates fee included in Initial Access fee. Subsequent annual fee is $800*

or

HIN Subsets

HIN Subsets** - Initial Access Fee (can select multiple)

Hospital Related ($5,000.00)
Alternate Care/Clinics ($3,000.00)
Pharmacies ($3,000.00)
Dialysis Centers ($2,500.00)
U.S. PHS 340B Entities ($2,000.00)
Nursing Homes ($1,000.00)

(Includes records contained within specified subset and on-going maintenance to records. Does not include online access)
**Data includes all assigned locations within a facility or campus.

* Invoiced in quarterly installments, beginning with the first calendar quarter following the date of distribution of the initial CD.

*** Processing fees may apply, invoiced monthly. Refer to the HIN request submission guidelines available at HIBCC’s HIN resource center or click here for detailed information.

Annual License Fees*
Hospital Related ~ $2,000
Alternate Care/Clinics ~ $4,000
Pharmacies ~ $1,500
Dialysis Centers ~ $1,000
U.S. PHS 340B Entities ~ $1,000
Nursing Homes ~ $1,000

or

Total

$0.00

Signature of Official Representative

By signing above I certify the information indicated to be correct and in accordance with the guidelines stated above.

Payment Information

Billing Company*

Billing Name*

First Last

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Telephone

Payment Information*

Pay by Credit Card
Please invoice me directly
Mailing a check or money order

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Credit Card Address is a*

Purchase Order #*

Check Number #*

Please mail check and money orders to:
HIBCC 2525 E Arizona Biltmore Circle, Suite 127 Phoenix, Arizona 85016

A completed Data License Agreement is required in addition to this form.

Email

This field is for validation purposes and should be left unchanged.

*Important Note for International Credit Cards

If you are paying with a Non-United States/Canada credit card, you must use the PDF version of the application, available for download here.

Organizational Information

Shipping Information

Media Specifications

Application Categories & Fees ***

Payment Information