Change Healthcare Enterprise Imaging Network™

First Name *

Last Name *

Business Email: *

Job Function * -- Please Select -- Administrative/Human Resources Administrator Billing/Coding Board Member/Director/Trustee Cardiology Care Management/Population Health Claims & Denials Consulting Dentistry EDI EHR Implementation/Management Engineering/Technical Staff Enrollment Executive Finance/Accounting General Management Information Systems/Technology Laboratory Legal/Regulatory/Compliance Medical Auditing Medical Practice Management Member Engagement Nurse/Nursing Executive Office Manager Operations Patient Access Patient Financial Services Pharmacy Physician Physician Practice Management Procurement/Purchasing/Supply Project Management Radiology Revenue Cycle Management Sales/Business Development/Marketing Training/Education Vendor Relationships Other

Job Level * -- Please Select -- Analyst/Administrator Chief Compliance Officer Chief Executive Officer Chief Financial Officer Chief Information Officer Chief Medical Information Officer Chief Medical Officer Chief Operating Officer Chief Quality Officer Chief Technology Officer C-Level Department Chair Director Doctor Individual Contributor Manager President Senior Vice President Vice President Other

Claims Volume

Company *

Company Type * -- Please Select -- Billing Service Dental Emergency Medical Service Government Agency Healthcare Information Exchange Home Health Agency Hospital Employed Practice Hospital/Health System Imaging Center Independent Practice Affiliated with Hospital Independent Practice Not Affiliated with Hospital Laboratory Partner/Reseller Payer Software Vendor Trust Other

Practice Specialty -- Please Select -- Anesthesia Cardiology Emergency Medicine Pathology Radiology Other

Number of Covered Lives

Practice Management Software Vendor

Business Phone *

State/Location * -- Please Select -- Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming -- Other Locations -- Canada Guam Puerto Rico U.S. Virgin Islands Other

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