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TX&NM Hospice Organization Membership Renewal & Application

Member Benefits

Chose one
Membership Category:
Dues:
Notes:
Licensed Provider

*Total Patient Revenue in 2009 Multiplied by .0007= _____

Minimum Dues:  $500

Maximum Dues:  $5,000

 

Licensed Alternate Delivery Site
$300

 

 

Developing Provider

$250

First Year

 

Individual Member (Any
individual with an interest in supporting
hospice is eligible for an individual
membership. **However, if you are employed by a hospice the hospice must be a member.**
$50

Entitles you to a listing in and a
copy of the membership directory,
newsletters, other publications and
member rates for all educational
opportunities. **However, if you are employeed by a hospice the hospice must be a member for you to receive these benifits. **

 

Patron Member (A patron member is
any individual, firm or organization which
desires to promote hospice.)
$300
Entitles the patron member to a
special listing in the Patron
Member Section of the Directory, a
copy of the Directory, newsletters,
other publications and
membership rates at all
educational opportunities

*Membership dues should be calculated by multiplying the total patient revenue for 2009 by .0007.  Each site with a different Medicare provider number should also make application for membership.  Licensed alternate delivery sites should pay the minimum fee of $300.  All sites paying dues will be entitled to a listing in the Membership Directory, all organizational mailings and faxes, and the member discount for all educational offerings. Corporations—3 largest locations pay actual dues up to $5,000 cap for each and all other locations pay minimum dues of $500 with an overall cap of $15,000.  T&NMHO Tax ID#: 75-1870672.

 

Name(organization or individual):
Contact Person (For Organization):
Street Address:
P.O. Box:
City:
State:
Zip Code:
Telephone:
FAX:
800 #:
Email Address:
Web Site:
Director:
Medical Director:
Counties Served:
Start of Operations Date:
Amount Due:
Credit Card Type:
Credit Card Number:
Card Security Code: What's this? Using Amex?
Expiration Date:
Name on Card:

Providers only, Check any that apply:
Operational: Independent:
Nonprofit: For Profit:  
Alternate Delivery Site: Primary Licensed Site:  
Home Health Based: Long Term Care Based:  
Hospital Based: Inpatient Facility:  
Medicare Certified: Medicaid Certified:  
Developing: NHO Member: