Provider Membership Form

Definition of Hospice Provider Member:

Any public or private agency, entity, center, institution or any distinct part of these organizations which is licensed by the state of Washington as a hospice agency or volunteer hospice and provides hospice care. Provider members have voting responsibilities and privileges.

Definition of Palliative Care Provider Member:

Any public or private agency, entity, center, institution, which is providing palliative care services and is recognized as a distinct palliative care program and is licensed by appropriate state oversight, if required.

The deadline for returning paperwork and payment for 2023 WSHPCO Provider Member dues is 4/7/23.

Save $200 on your membership renewal by paying before the deadline!

Annual direct lobbying costs are 0.9% of membership dues.

PAYING BY CHECK? Download PDF Provider Member Packet Here

WSHPCO Provider Member Information

This form is used to collect information about your program for inclusion on WSHPCO's website program directory. This also lets us know who within your program we can add to our various networking groups and newsletter list. Please complete the information, scroll to the bottom of the document and click "Submit". You will receive via email a confirmation and receipt of your payment. If you do not see your receipt, please check your spam or junk mail folder. You may also email mccauley@wshpco.org or call 503.890.7027 for website/payment troubleshooting.

Program Information

Please click on the services your program provides from the drop-down list below (multiple choices OK):(Required)

Hospice

Inpatient Hospice

Palliative Care

Inpatient Palliative Care

Other (please describe)

If you chose "Other" above, please describe.(Required)

Program Name(Required)

Program Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Program Phone Number(Required)

Program Website

Counties your program serves:(Required)

Cities your program serves:(Required)

Providing this information helps consumers find you better as they have an option to search for a hospice program by City. If too many to list here, please email a list of cities your program serves to mccauley@wshpco.org.

WSHPCO Provider Member Dues Calculation Area

Provider Member Category(Required)

Provider Member Fee - Rural Palliative Care Program(Required)

Price:

Provider Member Fee - Other(Required)

Price:

Provider Member Flat Rate - Medicare-Certified Hospice (including programs providing Palliative Care)(Required)

Price:

Dues are calculated using the following formula per provider number: Number of Admissions from January 1 through December 31, 2022 multiplied by $5.00 plus flat fee of $500. Hospice programs with 52 or fewer admits in year 2022 pay only the flat fee of $500. Example: if your program had 100 admits in 2022, your patient admit cost would be 100 x $5 = $500, plus the flat fee of $500 for a dues payment total of $1,000. If your program had 20 admits in 2022, your dues payment total would be $500. Hospice programs also offering palliative care services pay the $500 flat fee once. A hospice program's minimum dues payment is $500. For Medicare-Certified Hospice programs, including programs providing Palliative Care: Programs with multiple sites under 1 provider number please include all locations for total number of patient admissions and complete and return membership paperwork for each location.

Number of Patient Admits in Previous Calendar Year (Required)

Price: $5.00

Calculate the amount due using the following formula per provider number: Number of Admissions from Jan. 1 through Dec. 31, multiplied by $5.00.

Product Name

Hidden

Number of Hospice/Palliative Care Patients Admitted in 2022

Credit Card(Required)

Card Details

Cardholder Name

Provider Membership Total

Staff Contacts

Please complete this section so we know who to add to our WSHPCO networking groups and newsletter mailing list. Thank you!

Program Director or Administrator Name(Required)

First Last

Title/Position/Credentials(Required)

Program Director or Administrator Email(Required)

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Program Primary Contact (if different from Director or Administrator)

First Last

Title/Position/Credentials

Program Primary Contact Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Medical Director

First Last

Title/Position/Credentials

Medical Director Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

QAPI Coordinator

First Last

Title/Position/Credentials

QAPI Coordinator Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Hospice Biller

First Last

Title/Position/Credentials

Hospice Biller Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Hospice Volunteer Coordinator

First Last

Title/Position/Credentials

Hospice Volunteer Coordinator Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Clinical Contact

First Last

Title/Position/Credentials

Clinical Contact Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Social Worker

First Last

Title/Position/Credentials

Social Worker Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Bereavement Coordinator

First Last

Title/Position/Credentials

Bereavement Coordinator Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Spiritual Care Coordinator

First Last

Title/Position/Credentials

Spiritual Care Coordinator Email

Optional: please add this person to the WSHPCO networking lists below:

Hospice Medical Directors (group for Hospice Medical Directors only)

Inpatient Hospice Directors/Managers (group for Inpatient Hospice Directors/Managers people only)

Palliative Care

Pediatric Palliative Care

Public Policy

QAPI/Regulatory (Hospice Program Directors/Administrators automatically added to this group)

Volunteer Coordinators

Please add the additional people to the QAPI/Regulatory Networking Group:

Please list First & Last Name, Email Address

Please add the additional people to the Palliative Care Networking Group:

Please list First & Last Name, Email Address

Please add the additional people to the Pediatric Palliative Care Networking Group:

Please list First & Last Name, Email Address

Please add the additional people to the Public Policy Networking Group:

Please list First & Last Name, Email Address