Provider Membership Provider Membership InformationProgram Director/Primary Contact Name(Required) First Last Please tell us the name of the hospice/palliative care program director or primary contact.Program Director/Primary Contact Email Address(Required) Enter Email Confirm Email Credentials, Job Title for Program Director/Primary Contact(Required)Work Phone(Required) Country Phone Number Professional InformationOrganization Name(Required)Displayed in your profileOrganization Website Displayed in your profileOrganization Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Displayed in your profileOrganization Phone(Required) Country Phone Number Displayed in your profileCounties Served(Required)AdamsAsotinBentonChelanClallamClarkColumbiaCowlitzDouglasFerryFranklinGarfieldGrantGrays HarborIslandJeffersonKingKitsapKittitasKlickitatLewisLincolnMasonOkanoganPacificPend OreillePierceSan JuanSkagitSkamaniaSnohomishSpokaneStevensThurstonWahkiakumWalla WallaWhatcomWhitmanYakimaDisplayed in your profileCities Served(Required)AberdeenAirway HeightsAlbionAlgonaAlmiraAnacortesArlingtonAsotinAuburnBainbridge IslandBattle GroundBeaux Arts VillageBellevueBellinghamBenton CityBingenBlack DiamondBlaineBonney LakeBothellBremertonBrewsterBridgeportBrierBuckleyBucodaBurienBurlingtonCamasCarbonadoCarnationCashmereCastle RockCathlametCentraliaChehalisChelanCheneyChewelahClarkstonCle ElumClyde HillColfaxCollege PlaceColtonColvilleConconullyConcreteConnellCosmopolisCoulee CityCoulee DamCoupevilleCovingtonCrestonCusickDarringtonDavenportDaytonDeer ParkDes MoinesDuPontDuvallEast WenatcheeEatonvilleEdgewoodEdmondsElectric CityEllensburgElmaElmer CityEndicottEntiatEnumclawEphrataEverettEversonFairfieldFarmingtonFederal WayFerndaleFifeFircrestForksFriday HarborGarfieldGeorgeGig HarborGold BarGoldendaleGrand CouleeGrandviewGrangerGranite FallsHamiltonHarrahHarringtonHartlineHattonHoquiamHunts PointIlwacoIndexIoneIssaquahKahlotusKalamaKelsoKenmoreKennewickKentKettle FallsKirklandKittitasKruppLa CenterLa ConnerLaceyLaCrosseLake Forest ParkLake StevensLakewoodLamontLangleyLatahLeavenworthLiberty LakeLindLong BeachLongviewLymanLyndenLynnwoodMabtonMaldenMansfieldMaple ValleyMarcusMarysvilleMattawaMcClearyMedical LakeMedinaMercer IslandMesaMetalineMetaline FallsMill CreekMillwoodMiltonMonroeMontesanoMortonMoses LakeMossyrockMount VernonMountlake TerraceMoxeeMukilteoNachesNapavineNespelemNewcastleNewportNooksackNormandy ParkNorth BendNorth BonnevilleNorthportOak HarborOakesdaleOakvilleOcean ShoresOdessaOkanoganOlympiaOmakOrovilleOrtingOthelloPacificPalousePascoPaterosPe EllPomeroyPort AngelesPort OrchardPort TownsendPoulsboPrescottProsserPullmanPuyallupQuincyRainierRaymondReardanRedmondRentonRepublicRichlandRidgefieldRitzvilleRiversideRock IslandRockfordRosaliaRoslynRoyRoyal CityRustonSammamishSeaTacSeattleSedro-WoolleySelahSequimSheltonShorelineSkykomishSnohomishSnoqualmieSoap LakeSouth BendSouth Cle ElumSouth PrairieSpangleSpokaneSpokane ValleySpragueSpringdaleSt. JohnStanwoodStarbuckSteilacoomStevensonSultanSumasSumnerSunnysideTacomaTekoaTeninoTietonToledoTonasketToppenishTukwilaTumwaterTwispUnion GapUniontownUniversity PlaceVaderVancouverWaitsburgWalla WallaWapatoWardenWashougalWashtucnaWatervilleWaverlyWenatcheeWest RichlandWestportWhite SalmonWilburWilkesonWilson CreekWinlockWinthropWoodinvilleWoodlandWoodwayYacoltYakimaYarrow PointYelmZillahDisplayed in your profilePlease check all the services your program provides(Required) Hospice Palliative Care Inpatient Hospice Hospice & Palliative Care Other Select AllDisplayed in your profileEnter other services your program provides Add RemoveDistribution List interest? Bereavement Coordinators Networking Group Education/Conference Planning Group Inpatient DirectorManagers Networking Group (for Inpatient providers only) Medical Directors, Physicians, NPs Networking Group QAPI/Regulatory Networking Group Volunteer Coordinators Networking Group Not visible in your profileAdditional Staff ContactsNameEmailRole Add RemovePlease include additional staff member information so they can be added to WSHPCO distribution groups and newsletter mailings.Create Provider MembershipUsername(Required)Provider Membership UsernameProvider Membership Email(Required)Email used to log into wshpco.org Enter Email Confirm Email Provider Membership Password(Required) Enter Password Confirm Password Strength indicator Set a password to log into your wshpco.org Provider Membership Account. Membership & TotalHospice Type(Required) Hospice & Hospice + Palliative Care programs Volunteer Hospice “Stand Alone” Palliative Care Programs (not affiliated with a hospice program) Rural Palliative Care program (not affiliated with a member Hospice program) Volunteer Hospice(Required) Price: Rural Palliative Care program (not affiliated with a member Hospice program)(Required) Price: Stand Alone” Palliative Care Programs (not affiliated with a hospice program)(Required) Price: Number of Patients Admitted last calendar year?(Required)(Not visible in profile)Hospice & Hospice + Palliative Care programs with up to 52 annual admissions:(Required) Price: Hospice & Hospice + Palliative Care programs w/ 53+ annual admissions:(Required)$600 + $6 per patient admissions in previous calendar year Price: $600.00 Total
