OAASC Facility Member Application

Section 1. APPLICANT INFORMATION:

Facility
Address 1
Address 2
City State Zip
Phone
Fax
Web
Primary Contact - Admin Director
First Name
Middle
Last Name
Suffix
Title
Email
Additional Staff
Medical Director
Email
Director of Nursing
Email
Corporate Contact (if applicable)
Email
I do not give my permission to be solicited for OAASC PAC contributions.
A. Legal Type of Ownership:
 
B. Joint Venture:
If your center is a joint venture, please quantify the ownership %.
% Owned by Physician(s)
% Owned by Hospital
% Owned by Other
List Other
C. Accreditation:
 
D. Facility Specialty-Services Provided:
 
Type of specialty(s):
E. Facility Type:
 
F. Additional Information:
Number of Operating Rooms
Number of Procedure Rooms
Annual Number of Surgeries
Year Opened
Section 2. MEMBERSHIP FEE:
FORMULA: Take the total number of patients on which you performed procedures in the current most recent fiscal year and multiply by $.75 per patient, up to a maximum of $2,250 (3,000 patients per year). If your facility has been in existence for less than 1 year, please pay the minimum of $750.00.
If your ASC is part of a corporation or part of a larger system you are entitled to a volume discount based on the number of total facilities that are joining. The discounts are as follows:
2 Facilities: 25% Discount for Each Facility. Use the original calculation .75 x number of patients at the facility, then subtract 25%. Maximum Payment: $1,687.50 (Both facilities must join)
3 Facilities: 30% Discount for Each Facility. Use the original calculation .75 x number of patients at the facility, then subtract 30%. Maximum payment per facility would be $1,157.00 (All three facilities must join).
4 or More Facilities: 35% Discount for Each Facility. Use the original calculation .75 x number of patients at the facility, then subtract 35%. Maximum payment: $1,462.50 (At least 4 facilities must join).
Minimum Payment: $750.00
Maximum Payment: $2,250.00
BASE DUES AMOUNT: Facility open for less than 1 year
Number of patients X $.75 =
- Discount of applicable % = TOTAL DUES
   - denotes required fields