TX&NM Hospice Organization Membership Renewal & Application

See our Member Benefits

2017-2018 Membership Directory

If you are interested in becoming an "Individual Member" please call our office at 512-454-1247 for the application

Chose one
Membership Category:
Dues:
Notes:
Licensed Provider

*Total Patient Revenue in the past 12 months Multiplied by .0007= _____

Minimum Dues:  $500

Maximum Dues:  $5,000

 

Developing Provider
Free

First Year is free for Developing providers who have not recieved a Medicare number.

 

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 PLUS- Education Add-on

$550 per site + 10% of your Dues = Membership Plus Price

 

Includes unlimited access to all on-line education for the entire year. You can provide training to your current staff and utilize these education opportunities for new employee orientation. There are courses that include continuing education for all disciplines (excludes webinars). Includes all administrator, nurse, social worker, chaplain, bereavement, vol coordinator and in-service training. Over 70 hours.

*Membership dues should be calculated by multiplying the total patient revenue for the past 12 months by .0007. 

  • Each site with a different Medicare provider number should also make application for membership. 
  • All sites paying dues will be entitled to a listing in the Membership Directory, all organizational mailings, and the member discount for all educational offerings, member education freebies throughout the year, hospice job posting stie, members only website.
  • 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.

*Out of State Hospices Agencies (not TX or NM) that wish to be members can join for $500.

Name (Organization or Individual):
Contact Person (For Organization):
Street Address:
P.O. Box:
City:
State:
Zip Code:
Telephone:
FAX:
800 #:
Email Address (of the contact person for the agency):
Web Site:
Admin/Director:
Medical Director:
Alt. Admin
DON:
Counties Served:
Start of Operations Date:
Accreditation (ex:CHAP, JHACO)
Amount Due:
Credit Card Type:
Credit Card Number:
Card Security Code: What's this? Using Amex?
Name on the Card:
Expiration Date:

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: NHPCO Member:
Languages (other than English) Spoken by your staff: