2013 Hospice Membership Application: Main Site

Please complete the information below for the MAIN SITE ONLY. If your agency has Alternative Delivery Sites, you must also complete that application for each site, found on the Membership page.
Agency Information:
Agency
Address
City State Zip
Phone Toll Free Phone
Fax
Website
County (Primary Location)
Name of Person Completing Application
Executive Director:
Name
Email
  Primary Contact is Executive Director.
Primary Contact:
Name
Title
Email
Medical Director:
Name
Email
Accounts Payable Representative:
Name
Email
Volunteer Coordinator:
Name
Email
Patient Care Manager:
Name
Email
Bereavement Team Leader:
Name
Email
Medical Social Worker:
Name
Email
Marketing/Public Relations Representative:
Name
Email
Total Number of Patients for all sites served in most recent year of full data:
ALOS MLOS Average Daily Census
Ohio Hospice License #
Hospice Medicare Certification #
Agency type based on Medicare Filing Status:
Ownership:
Tax Status:
Does your hospice operate one or more dedicated hospice facilities or units?
Does your hospice have a dedicated Palliative Care Program?
Are you Accredited?
 If Yes, which accreditation do you have?
 
 Date of Last Visit: ?
Have You Received "Deemed Status Accreditation"?
Please select all counties that your organization serves:
This information is used in our Membership Directory
Adams Allen Ashland Ashtabula Athens
Auglaize Belmont Brown Butler Carroll
Champaign Clark Clermont Clinton Columbiana
Coshocton Crawford Cuyahoga Darke Defiance
Delaware Erie Fairfield Fayette Franklin
Fulton Gallia Geauga Greene Guernsey
Hamilton Hancock Hardin Harrison Henry
Highland Hocking Holmes Huron Jackson
Jefferson Knox Lake Lawrence Licking
Logan Lorain Lucas Madison Mahoning
Marion Medina Meigs Mercer Miami
Monroe Montgomery Morgan Morrow Muskingum
Noble Ottawa Paulding Perry Pickaway
Pike Portage Preble Putnam Richland
Ross Sandusky Scioto Seneca Shelby
Stark Summit Trumbull Tuscarawas Union
Van Wert Vinton Warren Washington Wayne
Williams Wood Wyandot
2013 Dues Calculation:
Please use your net patient revenue minus Medicaid room and board. Use the most recent complete year of revenue.
Your dues are based on the following table:
Revenue : Dues
Startup, not licensed yet: $500
Licensed and below $500,000: $750
$500,000 to $750,000: $1,000
$750,000 to $1,000,000: $1,750
$1,000,001 to $1,500,000: $2,500
$1,500,001 to $3,000,000: $4,000
$3,000,001 to $7,000,000: $6,500
$7,000,001 to $10,000,000: $7,500
$10,000,001 to $15,000,000: $8,000
$15,000,001 to $25,000,000: $9,000
$25,000,001 to $35,000,000: $10,000
$35,000,001 to $50,000,000: $11,000
$50,000,001 to $70,000,000: $12,000
$70,000,001 to $90,000,000: $13,500
$90,000,001 and up: $15,000
Once you have determined your net patient revenue, please enter it here:
Membership Discount Program
In an effort to assist programs with rising costs we are facing in today's economy, Midwest Care Alliance is pleased to offer a discount program of 10% off of total dues if both home care and hospice join Midwest Care Alliance and dues are paid in full.
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