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| 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.
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| Agency Information:
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| Agency | |
| Address | |
| City | State Zip |
| Phone | Toll Free Phone |
| Fax | |
| Website | |
| County | (Primary Location) |
| Name of Person Completing Application | |
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| Executive Director:
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| Name | |
| Email | |
| | Primary Contact is Executive Director. |
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| Primary Contact:
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| Name | |
| Title | |
| Email | |
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| Medical Director:
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| Name | |
| Email | |
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| Accounts Payable Representative:
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| Name | |
| Email | |
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| Volunteer Coordinator:
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| Name | |
| Email | |
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| Patient Care Manager:
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| Name | |
| Email | |
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| Bereavement Team Leader:
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| Name | |
| Email | |
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| Medical Social Worker:
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| Name | |
| Email | |
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| Marketing/Public Relations Representative:
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| Name | |
| Email | |
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| Total Number of Patients for all sites served in most recent year of full data:
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| ALOS | MLOS | Average Daily Census |
| Ohio Hospice License #
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| Hospice Medicare Certification #
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Agency type based on Medicare Filing Status:
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| Ownership:
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| Tax Status:
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| Does your hospice operate one or more dedicated hospice facilities or units?
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| Does your hospice have a dedicated Palliative Care Program?
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| Are you Accredited?
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| | If Yes, which accreditation do you have? |
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| | Date of Last Visit: ?
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| Have You Received "Deemed Status Accreditation"?
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| Please select all counties that your organization serves:
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| This information is used in our Membership Directory
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| 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 |
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| 2013 Dues Calculation:
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| Please use your net patient revenue minus Medicaid room and board. Use the most recent complete year of revenue.
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| Your dues are based on the following table:
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| Revenue : Dues
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| Startup, not licensed yet: $500
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| Licensed and below $500,000: $750
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| $500,000 to $750,000: $1,000
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| $750,000 to $1,000,000: $1,750
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| $1,000,001 to $1,500,000: $2,500
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| $1,500,001 to $3,000,000: $4,000
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| $3,000,001 to $7,000,000: $6,500
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| $7,000,001 to $10,000,000: $7,500
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| $10,000,001 to $15,000,000: $8,000
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| $15,000,001 to $25,000,000: $9,000
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| $25,000,001 to $35,000,000: $10,000
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| $35,000,001 to $50,000,000: $11,000
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| $50,000,001 to $70,000,000: $12,000
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| $70,000,001 to $90,000,000: $13,500
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| $90,000,001 and up: $15,000
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| Once you have determined your net patient revenue, please enter it here:
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| Membership Discount Program
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| 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. |
