New York Digital Health Accelerator 2015 – Application Form      Applications to the Accelerator Program will be accepted starting Wednesday, April 8, 2015. All applications are due by 11:59:59 pm EST on Monday, May 18, 2015. Check the FAQ on Accelerator website for answers to any questions regarding the application. Please direct any remaining questions to the mailbox: [email protected] Please Note: you will not be able to save a partial application and if you log out before submitting you will lose anything entered. Combined Applications Two companies may propose a combined technology solution to be considered for this year's class subject to the following: 1) The terms of the partnership (financial, technological, etc) need to be worked out between the two partners in advance of submitting an application. 2) One of the partners should be designated the lead. 3) One of the partners must be headquartered with the majority of its employees in New York. Senior management of the other partner must commit to spend meaningful time in NYC during the 4 month program. 4) Each partner can take the $100,000 convertible note at their option. The program will take common stock warrants (1.5% of fully diluted, subject to reduction if the company has raised significant amounts of outside capital) in each of the partners. 5) Neither partner can have in excess of $10mm of revenues in 2014. Applications for combined technology solutions will be evaluated on their ability to reduce, rather than increase, complexity for the provider or payor. Note: To submit a combined application, each company must apply separately, and in addition submit the Combined Application Form. Instructions       Please answer all questions within the space provided. If any required fields do not apply to your company, please write "N/A" in the space provided. Application cannot be saved for later completion. Once you start the application you must complete it in full, partially completed applications cannot be saved. We suggest that you scroll through the entire application and put together all the information that would be needed before you begin. Upon submission you will receive an email that will contain a copy of your completed application. If after submitting the application you realized that you made an error, you will unfortunately need to resubmit the entire application. NOTE: The online application will time out after approximately 90 minutes, so it’s highly recommended that you type out your answers offline before copying and pasting them into the online application. Please also note that the character limit for individual questions includes spaces between words. Start Your Survey *Email Address: *Verify Email Address: Application *Email: *Verify Email: *First Name: *Last Name: *Job Title: *Company/Organization: *Country: *Address Line 1: Address Line 2: *City: *US State/Canadian Province: *Zip (Postal Code): *Work Phone: Survey Questions Please Note: you will NOT be able to save a partial application and if you log out before submitting you will lose anything entered. I. SUMMARY Elevator Pitch: In 600 characters or less, please describe your core product/service and its value proposition: *Product Category (check all that apply):  Care Coordination (Collaborative care solutions that reflect the continuum of information on a patient and that support team-based care)  Patient Engagement (Personal health management solutions, facilitating better healthcare decisions and improving care management communications)  Workflow Management (Improving provider healthcare workflow processing and throughput) *Briefly explain how your product fits in the selected category (ies) (in 700 characters or less) The SHIN-NY is a secure network that allows healthcare providers to access and exchange patient records across the state. Innovators looking to develop software products that meet healthcare providers’ needs will, in the future, be able to make use of the SHIN-NY Application Programming interface (API). The API’s initial capabilities will focus on Patient Record Lookup (PRL), a standards-based, secure approach to obtain all of the clinical records for a patient from the SHIN-NY. *How would you leverage your access to the Statewide Health Information Network of New York (SHIN-NY)? (in 600 characters or less) *At what phase is your product?  Pre-product  Product in beta  Product in production at client(s)  Product in production with revenue *Please record a 3 minute video pitch and provide the public/private link. Videos can be shared through sites like Vimeo or YouTube (Note: Password protected videos will NOT be accepted) II. INFORMATION ABOUT YOUR COMPANY Company URL, if any: *Describe your company and the services it provides (in 3,000 characters or less) *Date (Month, Year) company was founded *Has the company previously applied to the NYDHA Program?  Yes  No *How many employees in total? Please provide a breakdown by department. (in 600 characters or less) *Please list your core team members and their roles. (in 2,500 characters or less) *Please provide short bios for up to four key management team members, including education, experience, and notable accomplishments. You may include links to your LinkedIn profile as well. (in 5,000 characters or less) *How do the team members/founders know each other? (in 1,500 characters or less) *Do any of the team members have other commitments or obligations that would prevent them from committing full time to the company during the program?  Yes  No III. THE MARKET *Describe the initial target market for your product: (in 2,500 characters or less) *Who are your major competitors in the space, and what differentiates your product from theirs? (in 2,500 characters or less) *What makes your product/service difficult to duplicate? (in 2,500 characters or less) *What is your product's value proposition? (in 2,500 characters or less) *Please describe the type of integration your product requires with a providers existing systems: *What is the product's revenue model? (in 2,500 characters or less) IV. DEVELOPMENT PLAN AND ROADMAP *Please describe your product roadmap over the next 24 months. Be sure to include checkpoints at 3 months, 6 months, 12 months, and 24 months. (in 2,500 characters or less) Please provide a URL to prototypes or demos of your product or beta (if applicable) (Note: Password protected videos will NOT be accepted): *Please provide a listing of your beta customers, both ongoing and scheduled. If in production, please identify existing customers. Please provide full contact information from at least 3 reference clients. (in 2,500 characters or less) V. FINANCIAL *What are your current revenues (if any)? (in 1,500 characters or less) *Please provide a projection of your product’s P&L / Cash-Flow statement for the upcoming 12 months. Note: Please make sure that the file name is composed only from letters and digits, with no special characters or symbols (e.g., '@', '$', '*', "%", etc.). +Add File *Please provide a current capitalization table that includes a high-level ownership breakdown (founder stock, Series A and other preferred, common, option pool, etc.):  Attachment or  Free text (3,000 characters limit) Outside funding raised: (select all that apply)  None  Seed – Lead Investors (in 500 characters or less)  Series A – Lead Investors (in 500 characters or less)  Series B – Lead Investors (in 500 characters or less)  Series C – Lead Investors (in 500 characters or less)  Convertible Debt – Lead Investors (in 500 characters or less)  Other (e.g. grants, consulting, etc.): o Describe  Date of most recent outside funding: (in 500 characters or less) VI. LEGAL *Did company employees write the code and/or have all legal rights to it?  Yes  No *Please list any existing non-compete arrangements or intellectual property agreements that impact your product (e.g. university-owned technology) (in 2,500 characters or less): *Are there any conflicts that might arise with any of the provider organizations or venture capital firms participating in the Accelerator Program?  Yes  No *Have any members of the team been convicted of any crime?  Yes  No *Are you eligible to work in the U.S. for the duration of the program? (Please note that the Accelerator Program does not sponsor visas)  Yes  No VII. GENERAL QUESTIONS Please note that the Accelerator program is available only for companies that have established an office in New York State. *Is your company based in New York State?  Yes  No *On which date(s) are you available to interview in New York City? (please check all that apply)  Wednesday, July 8, 2015  Thursday, July 9, 2015 *How did you hear about the program? *If accepted, what benefit(s) do you look forward to gaining from the accelerator program. Please be specific. (in 2,500 characters or less) VIII. ACKNOWLEDGEMENT The undersigned acknowledges that the information provided in this application may be provided to (i) the New York eHealth Collaborative, the Partnership Fund for New York City, the New York State Department of Health, the Empire State Development Fund, and the New York Digital Health Accelerator and each of their respective affiliates, employees, consultants, volunteers and advisors, (ii) members of the judging panel and program sponsors and (iii) senior officers of the participating provider organizations on a “need to know” basis in connection with the review of the application. The undersigned further acknowledge that the New York eHealth Collaborative, the Partnership Fund for New York City, the New York State Department of Health, the Empire State Development Fund, and the New York Digital Health Accelerator will not have any obligation to provide funding with regard to any submitted application. IX. CERTIFICATION OF APPLICATION We certify the accuracy of the information included in this proposal. *Company Name: *President/CEO: *Date: *Electronic Signature (just type your name):