Membership Application

TXNM Hospice Organization Membership Renewal & Application

Membership Category:	Dues:	Notes:
Licensed Provider	*Total Patient Revenue in 2007 Multiplied by .00065= _____	Minimum Dues: $400 Maximum Dues: $4,000
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.)	$50	Entitles you to a listing in and a copy of the membership directory, newsletters, other publications and member rates for all educational opportunities.
Patron Member (A patron member is any individual, firm or organization which desires to promote hospice.)	$250	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 2007 by .00065. 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 $4,000 cap for each and all other locations pay minimum
dues of $400 with an overall cap of $12,500. 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:
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: