HT4M Membership Application

HT4M Member Information
Join the HT4M Community!

Membership with Health Tech for Medicaid (HT4M) provides unparalleled opportunities for networking, collaboration, and access to exclusive events and resources. Our members play a vital role in advancing healthcare equity and innovation in the Medicaid space.

Membership fee: $5,000 annually.

We understand that the cost of membership may be a consideration. We offer flexible payment plans to accommodate your needs. Reach out to us at info@ht4m.org for more information.

Join us today and become part of a dynamic community dedicated to driving transformative change in Medicaid!
About Your CEO/Founder
CEO/Founder Name:*

First NameLast Name
We highlight our members by including your CEO/Founder of the company on our website. Please tell us their Title/Position (as you want it on our website):*
CEO/Founder Email:*
example@example.com
CEO/Founder Phone Number:*

Area CodePhone Number
CEO/Founder Twitter (X) Handle:
CEO/Founder LinkedIn:
CEO/Founder Instagram:
Upload CEO/Founder headshot:*

Browse Files
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If you have someone who schedules for you, please share their information:

First NameLast Name
Email:
example@example.com
Please list an additional marketing person we should contact with any information we may have to disseminate. This person may be a direct report, a colleague, an Admin, etc.
Marketing Contact Name

First NameLast Name
Title
Email
example@example.com

About Your Company
Company Name:*
Website URL:*
Company Twitter (X) Handle:*
Company LinkedIn:*
Company Instagram:
Year Founded:*
Headquarters City:*
Headquarters State:*
Upload your company's logo: *

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What type of business is your company?*

Health technology startupPublic or privately held (self-funded) companyHealth PlanHealth System or ProviderNonprofitIndustry ConsultantVenture Capitalist/FundOther

Follow up For Non-Profit Organizations
Tell us about your organization's connection to the Medicaid population, and your interest in collaborating with HT4M members.*

Follow Up For Consultants
Tell us about your health sector expertise and the services that you offer clients.*
Are you a former State Medicaid Director?*

YesNo
If you are a former State Medicaid Director, please list the state program(s) that you managed:

Follow Up For Investors, Venture Capitalists, and/or Funds
Date of your most recent fund announcement:*

MonthDayYear
Date
How much was your most recent fund:*
Total fund history:*
Do you currently invest in health technology startups?*

YesNoWe're getting into the sector
If you currently invest in health technology, please list a few portfolio companies:*
Are you planning to announce a new fund in the next 12 months? [This information will be kept confidential and is for record keeping only]*

YesNoOther
Please list an additional person who should receive our invitations, updates, opportunities and emails. This person may be a colleague, a direct report, an Admin, etc.
Name

First NameLast Name
Title
Email
example@example.com

Membership Dues

Membership dues are $5,000. Member registration will not be completed until dues have been received.
I plan to pay my dues (directions will be sent with invoice):*

Via checkVia ACHPlease contact me directly to discuss payment
I would like to pay my dues:*

In fullIn installments
Name of the accounting contact we should send your membership invoice to:*

First NameLast Name
Email of the person we should send your invoice to:*
example@example.com
Phone Number of Accounting Contact*

Area CodePhone Number
Your business address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, I certify that my organization will and is able to pay our annual membership dues.
Signature

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HT4M Member Information