Facility Membership Application

Company Information

Company Name
Address
City State Zip
Phone
Fax
Web Address

Personnel

Administrator
Email
Nursing Director
Email
Medical Director
Email
Business Manager
Email
Please check here if you wish to opt-out of the email broadcasts.
Legal Type
% Owned by Physicians
% Owned by Hospital
% Owned by Other
Facility Type
Freestanding
Physician Office Based
Hospital Affiliated
Multi Specialty
Single Specialty (please list:)

Certification

Proof of certification required. Please provide a copy of one of the following certificates with your application.

CA State License #
Medicare Certified #
Accreditation: (check all that apply)
  AAAASF
  AAAHC
  IMQ
  TJC
Year Opened
Number of Cases Annually
Do you joint venture with other physicians? Yes

Membership Fees

Membership fees are due upon joining.

Renewals are pro-rated and billed for annual January payment.

MEMBERSHIP FEE SCHEDULE
Membership Type
Were you referred by a member or partner?
(please enter the name)

PAC Contribution

The CASA PAC is a voluntary political organization that contributes to candidates for state office who share our philosophy and vision of the future of medicine. Political law and the CASA PAC Committee determine how your contribution is allocated. Contributions to PAC’s are voluntary and not limited to the suggested amounts.
PAC Contribution Rules: Corporate/Company can contribute $7,300 per calendar year. If individual owns 50% or more of the contributing company, the individual’s personal contribution and the company’s contribution cannot total more than $7,300. PAC contributions can only be used for campaign contributions. These funds cannot be used to pay for lobbying efforts (KP Public Affairs).
Contributions are not deductible for state or federal income tax purposes.

PAC DONATION DISTRIBUTION

If you are unable to contribute to the CASA PAC fund please consider contributing to the following options:
CASA ISSUES PAC
CASA Advocacy Fund

Voluntary PAC Contribution

 

Code of Conduct for CASA Members

By submitting an application for membership or for renewal of membership, the Facility, Individual and / or Vendor acknowledges that it has reviewed the CASA Code of Conduct and Bylaws, and pledges, without reservation to adhere to the standards of practice and conduct set forth therein, with regard to the quality of ambulatory care provided and the management of all other aspects of the member’s operations as well as with regard to participation in the credentialing process itself. To review CASA’s complete Bylaws & Code of Conduct, please visit www.casurgery.org.

I have read and agree to the Code of Conduct for CASA Members
(please intial)
   - denotes required fields