NCHICA NCHICA

Printable Membership Application

If you wish to mail or fax your membership application, please click here for a printable membership application.

The North Carolina Healthcare Information and Communications Alliance, Inc. (NCHICA) is a nonprofit membership corporation. Membership is open to any healthcare provider, persons providing services to healthcare providers, governmental entities, educational or scientific research organizations, and other non-governmental entities serving the healthcare industry. Membership, unless otherwise provided by the Board of Directors, will be required for participation in any of the projects sponsored by NCHICA. You need to know your category of membership and annual dues in order to complete this form. If you are not sure of these, please see our Membership Categories and Dues Structure page. Applicants are accepted for membership upon submission of this completed application, payment of the annual dues for the first year of membership, and acceptance of the "Terms of Membership" below. 

Terms of Membership

  1. A fundamental purpose of NCHICA is to facilitate the development of a statewide healthcare information network incorporating open architecture, interoperable systems, and reconfigured information systems. Consequently, Applicant agrees to support the following principles:
    1. to foster interoperability and open-systems architecture
    2. to work in good faith to integrate existing healthcare information systems
    3. to provide expert personnel to support the activities of NCHICA in the spirit of collaboration
    4. to support policies adopted by NCHICA to protect intellectual property
    5. to encourage a competitive environment for the development of the information, telecommunications, and telemedicine industries in North Carolina consistent with NCHICA's purposes.
  2. Applicant understands and agrees that, upon submission of this application, Applicant will become a member of a North Carolina non-profit corporation, and that Applicant will only have the rights and powers granted to members. Applicant will abide to the bylaws and policies as set forth in the North Carolina Non-Profit Corporation Act. Applicant understands that no joint venture, agency, or partnership will be created between Applicant and NCHICA or any of its members.
  3. Applicant understands that NCHICA is a publicly supported, tax-exempt organization under Section 501(c)(3) of the Internal Revenue Code. Consequently, NCHICA is subject to all the limitations imposed on such organizations and Applicant understands and agrees that NCHICA must serve public rather than private interests. Applicant understands that NCHICA's policies or operations may need to be modified in the future to comply with Section 501(c)(3). Applicant agrees at all times to support the rules, regulations, and provisions of federal tax law that apply to NCHICA.
  4. Applicant understands and agrees that (1) no part of the net income of NCHICA may inure to the benefit of any private person; (2) NCHICA will not, as a substantial part of its activities, carry on propaganda nor otherwise attempt to influence legislation, and will not participate in, nor intervene in (including the publishing or distribution of statements) any political campaign on behalf of or in opposition to any candidate for public office; and, (3) upon the dissolution of NCHICA, Applicant's membership in NCHICA will terminate and NCHICA's assets will be distributed for one or more exempt purposes within the meaning of Section 501(c)(3), or will be distributed to the federal government, or to a state or local government, for a public purpose.
  5. Applicant will abide by the Articles of Incorporation, Bylaws and policies of NCHICA, including, among other things, intellectual property policies and the use of NCHICA's trademarks and logos.
  6. Applicant will maintain the confidentiality of restricted technical data and reports received from NCHICA with the same degree of care that it protects its own confidential and proprietary information. If Applicant is a consortium, Applicant will use restricted technical data and reports only within the central facility and will not allow further dissemination without NCHICA's express permission.
  7. Applicant agrees that the information provided in this application is true and complete, that Applicant qualifies for a Membership in the category specified, and that this Application has been approved by all necessary organizational actions of the Applicant. Applicant agrees to pay the annual dues associated with the Applicant's Membership category.
Applicant Organization: ______________________________________________
By (Principal Representative Signature): ______________________________________________
Title of Principal Representative: ______________________________________________
Date: ______________________________________________

Please fill out and mail or fax to:

North Carolina Healthcare Information and
Communications Alliance, Inc. (NCHICA)
3200 Chapel Hill/Nelson Blvd.
Cape Fear Building, Suite 200
PO Box 13048
Research Triangle Park, NC 27709-3048
Phone: 919-558-9258
Fax: 919-558-2198