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: Select All Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Agency 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 Agency Phone*Website Counties Served*Review your listing from last year: https://wshpco.org/directory-search/ If no changes, use "same as last year" in the text field.Cities Served*Review your listing from last year: https://wshpco.org/directory-search/ If no changes, use "same as last year" in the text field.Provider Member Dues Calculation FormProvider Member Category*Medicare Certified Hospice ProgramVolunteer Hospice ProgramState Licensed Hospice ProgramPalliative Care ProgramPlease choose provider typeAdmissions in previous year Did you have 60 or less admissions in the previous year Did you have 60 or more admissions in the previous year Number 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?* YES NO Annual Due* Price: Total Update Additional Staff Contact InformationWSHPCO membership extends to the entire staff of the member organization. WSHPCO members receive the weekly eNews, information, notices and access to various list-serves and networking groups.Clinical Contact (Primary Contact, Patient Care Coordinator, etc.) Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Hospice Medical Director 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 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 Social Worker Name Email Optional - Please add this person to the following distribution lists: Palliative Care Networking Pediatric Palliative Care Public Policy QAPI/Regulatory Please add these additional staff members to the Palliatve Care Networking group:Please list names/job titles/email addresses for additional staff members to include in WSHPCO mailings.Please add these additional staff members to the PEDIATRIC Palliatve Care Networking group:Please list names/job titles/email addresses for additional staff members to include in WSHPCO mailings.Please add these additional staff members to the Public Policy Networking group:Please list names/job titles/email addresses for additional staff members to include in WSHPCO mailings.Please add these additional staff members to the QAPI/Regulatory Networking GroupPlease list names/job titles/email addresses for additional staff members to include in WSHPCO mailings.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 Credit CardCard Details Cardholder Name Total
