Developing Provider Request | Texas New Mexico Hospice & Palliative Care Organization

Developing Provider Request

Starting a new hospice and not yet Medicare certified? The Developing Provider membership is the perfect way to engage with TNMHPO and build a solid foundation for your agency. Use this form to submit a developing provider request and we’ll be in touch soon. Approved developing providers will receive a one-year complimentary membership. For questions about completing this form, contact our team directly.

"*" 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

People

Primary Contact Person for TNMHPO Member Account*

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

First Last

Primary Email for TNMHPO Member Account*

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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.

Key Staff List

Keep your staff in the loop on trainings, conferences, and hospice news from TNMHPO! 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

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SERVICE AREA

Hidden

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

Note to TNMHPO Membership Staff:

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

The TNMHPO Developing Provider Membership is complimentary for one year.

The TNMHPO Education Subscription 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 Education Subscription is just $650. For multi-site providers to qualify for an education subscription, each location with a different Medicare number (within the states of Texas or New Mexico) must be a member. Please note that education subscription pricing is per location.

Yes! We're interested in learning more about the Education Subscription.

Comments

This field is for validation purposes and should be left unchanged.

People

SERVICE AREA

Organizational Structure

Online Education

Upcoming Events

Hospice Chaplain & Bereavement Conference

Regulatory Compliance Conference

Resources