Applying for Bronx RHIO Membership

Please check if your organization is already a member of the Bronx RHIO by checking our Directory of Participants. If your organization is not a member of the Bronx RHIO, the CEO of your facility must complete and return the Bronx RHIO Application for Participation, the Bronx RHIO Participation Agreement, and the Participant Risk Assessment to become a participant.

You may fill out the documents through our automated e-signature application linked above or by hand — after downloading — via the instructions provided below.

If you have any questions, please email information@bronxrhio.org.

Bronx RHIO Application Instructions

To complete the Bronx RHIO Application on your computer:

  1. Download the Application to your desktop.

  2. Right click the downloaded file and open it with your desktop PDF viewer (Adobe Acrobat preferred).

  3. Fill out ALL relevant fields in the application in your desktop PDF viewer and save the file to your desktop. Note: Filling out the application in your internet browser will NOT allow it to save.

  4. If you are unable to sign the Application electronically (page 7), follow the instructions below to sign by hand.

  5. Email the completed application to information@bronxrhio.org.

To sign the Application by hand:

  1. Print out the signature page of the Application (page 7).

  2. Fill out page 7 of the Application with authorized signer’s name, signature, title, and the date.

  3. Scan and email to information@bronxrhio.org OR fax to (718) 708 7272.

To complete the Participation Agreement:

  1. On page 24 of the Participation Agreement, place an address (mailing or e-mail) to which official notices can be sent.

  2. On page 26 of the Participation Agreement:

    1. Write the name of your organization on the line titled “Name of Participant”

    2. Below, sign on the signature line titled “By:”

    3. Write your name and title below the signature line

  3. If you are unable to sign the Participation Agreement electronically, repeat the instructions to sign the Application by hand.

  4. Email to information@bronxrhio.org OR fax to (718) 708-7272.

To complete the Participant Risk Assessment:

  1. Please complete the contact information on the first page.

  2. Please write “Yes” or “No” only in the box directly below the instruction “Response Yes/No.”

  3. Please write an explanation of your selection of either Yes/No in the space marked “Participant Explanation” where you deem necessary, but especially when you select “No” for a statement.

  4. Please do not write in the space marked “Bronx RHIO Notes.” This is for Bronx RHIO staff use only.

  5. Email to information@bronxrhio.org OR fax to (718) 708-7272.