Membership Application

TX&NM Hospice Organization Membership Renewal & Application

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: