The number of health information exchanges (HIEs) has grown considerably since the first survey of the field in 2004. HIEs currently exist in every state. Some HIEs have been in existence for many years, while others are newly formed. Regardless, all communities recognize that the environment for HIE has changed considerably with the passage of the American Recovery and Reinvestment Act (ARRA). A more vigorous federal government role, in health information exchange and federal funding through several programs to drive information exchange, offers business opportunities that did not exist during the first HIE survey. Nevertheless, the initial steps in the creation of an HIE remain constant. This module of the toolkit provides an overview of those areas for consideration. Following this are sample documents from the HIE development process undertaken by mature HIEs, as development is measured by the eHealth Initiative Development Index, as well as documents from the operational plans of state designated entities (SDEs) for HIE.