Renew Provider Membership Form Renew Provider MembershipEnter your Agency Email Agency Name*Administrator/Director Name: First Last Administrator/Director Email* Enter Email Confirm Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Website Counties Served*Cities Served*Provider Member Dues Calculation FormProvider Member Category*Medicare Certified Hospice ProgramVolunteer Hospice ProgramState Licensed Hospice ProgramPalliative Care ProgramPlease choose provider typeAdmissions in previous yearDid you have 60 or less admissions in the previous yearDid you have 60 or more admissions in the previous yearNumber of admissions from previous year from 1/1 to 12/31* Price: $0.00 Quantity: Calculate the amount due using the following formula per provider number: Number of Admissions from Jan. 1 through Dec. 31, multiplied by $5.00. Does Your Program Provide Both Hospice & Palliative Care?*YESNOAnnual Due* Price: $300.00 Total $0.00 Update Additional Staff Contact InformationWSHPCO membership extends to the entire staff of the member organization. WSHPCO members receive information, notices and access to various list-serves.Clinical Contact Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Medical Director/Physician/NP Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Social Worker Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Bereavement Coordinator Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Volunteer Coordinator Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Spiritual Care Coordinator Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Biller Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory QAPI Coordinator Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Other StaffPlease list names/job titles/email addresses for additional staff members to include in WSHPCO mailings.Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Renewal Total and paymentBilling Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name
