2022 Developing Provider Request

The information submitted for your organization will be used in our membership directory and hospice guidebook. Please take a moment to ensure your hospice name appears exactly as you prefer to see it reflected in the member directory.

Developing Provider Membership Request and Profile

"*" indicates required fields

Organization*

Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address (If different than physical address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Website

800 # (If applicable)

Fax

Primary Contact Person for TNMHO Member Account*

Who should we ask for if questions come up about your TNMHO member account?

First Last

Primary Email for TNMHO Member Account*

Preferred Email for Hospice Locator Page (intake)

If your organization uses a specific email address for patient intake, let us know and we will post this email address on your hospice locator page.

PEOPLE

Key Staff List

Keep your staff in the loop on trainings, conferences, and hospice news from TNMHO! When discipline-specific training and events come up, we will forward information directly to the appropriate staffer. (i.e. We Honor Veterans, chaplain training, billing conference, regulatory conference, etc.) We are happy to save administrators from endless email forwarding. You're welcome! Use the + button to add up to eight staff contacts.

Name

Title

SERVICE AREA

Counties Served

Please list each county served by your organization, in alphabetical order. Avoid listing service area by regions, please, as the hospice locator tool relies on the county list. Thank you!

ORGANIZATIONAL STRUCTURE

Organization Details

We want to better understand and effectively segment our membership. Please check all the apply:

For-profit

Nonprofit

Primary Licensed Site

Stand Alone (independent)

Hospital-based

Inpatient Facility

Seeking acceditation? If so, which agency? (We have discount agreements that may be helpful!)

Start Date of Operations

DUES

Developing Provider Membership is complimentary for one year.

Membership Plus is an optional subscription: Train your whole staff - accessible all year - from our extensive online library. There's something for each hospice discipline. Membership Plus is just $650. FYI: For multi-site providers to qualify for Membership Plus, each location with a different Medicare number (within the states of Texas or New Mexico) must be a member. Please note that Membership Plus subscription pricing is per location. For more information paste this link into a new tab of your browser: https://www.txnmhospice.org/education/ Check the box below to add Membership Plus to your e-invoice!

YES! Please add Membership Plus online education access to our account!

Email for Membership Plus Invoice

If you are going with Membership Plus, let us know where to route your e-invoice:

Note to TNMHO Membership Staff:

Any additional information you want us to be aware of? Feel free to share it here.

Comments

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THANK YOU for your interest in the TNMHO member community.