HCIStack Vendor-Provider Application

Point of Contact Info

Let's get some information about you
What is your email? *
Name *

First Name Last Name
What is your title? *
What is your role?
Phone Number *

Area Code Phone Number

Tell us about your business model

Tell us a bit more about how your business works?
Do you offer multiple products? *

Yes No
Tell us about each product *
Tell us about your pricing structure? *
Who is your target customer? *
Clinical Model *

Talk to us about your current progress

What are you doing now?
What is your new product pipeline? *
What is your annual revenue *

A few more questions
Verify you are certified HIPAA compliant? *
Upload your most current Cyber insurance policy. *

Cancel of
Upload your most current annual risk assessment. *

Cancel of
What is the architecture of your platform? *
What are your cloud or API integrations? *
What devices or technical requirements are needed for your system? *

The next three questions are providing client references.

Client Reference 1

Tell us a bit about some clients you have worked with
Organization or company name *
Point of contact's name *
Location *
Contact email *
Product or services being utilized *
Client Reference 2

Tell us a bit about some clients you have worked with
Organization or company name *
Point of contact's name *
Location *
Contact email *
Product or services being utilized *
Client Reference 3

Tell us a bit about some clients you have worked with
Organization or company name *
Point of contact's name *
Location *
Contact email *
Product or services being utilized *
Should be Empty: