2019 IVI Organizational Membership Application
Thank you for your interest in joining the Innovation and Value Initiative. Please complete the following membership application to start the membership process. Please note that IVI will send you confirmation of your application as well as an invoice to submit dues.

We look forward to working with you to create an open and collaborative environment that brings together the best ideas and methods to improve value assessment in a rapidly evolving healthcare marketplace.

Email address *
Membership Type *
Organization *
Organization Web Address *
Stakeholder Sector *
Primary Membership Contact Information
Please provide information for the Primary Point of Contact for IVI activities. This person will receive IVI correspondence and newsletters, participate in meetings, and qualify for Committees and Board of Directors.
Preferred Prefix *
First Name *
Last Name *
Degrees *
Title *
Organization Name
Email Address *
Phone Number
Street Address One *
Street Address Two
Zip Code *
If relevant, please provide the name and email address for primary member's assistant.
Financial Point of Contact Information
Please provide contact information for person who should receive membership invoices or financial questions if different from above.
Preferred Prefix
First Name
Last Name
Title
Email Address
Phone Number
Organization's Background Information
Please share a little with us about your priorities and interests in the organization
How would you like to be involved in IVI? (Check all that apply)
Please mark any priority areas for you or your organization.
How did you learn about IVI? (Check all that apply) *
Required
Please contact my organization about joining IVI's Innovator's Circle.
Financial Information
Please provide basic financial information regarding your organization. Dues are based on your organization's annual revenue and type of organization. A dues schedule is attached, and IVI will send you an invoice for membership dues, upon receipt of your application. Membership will be activated upon receipt of payment.
IRS Classification
Annual Revenue *
Thank you for your application! We look forward to working with you on our common mission.
Submit
Never submit passwords through Google Forms.
This form was created inside of Momentum Health Strategies LLC. - Terms of Service