Renew Provider Member Membership Form Renew Provider MembershipEnter your Agency Name Agency Name*Administrator/Director Name: First Last Administrator/Director Email* Enter Email Confirm Email 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 ProgramMedicare Certified Hospice & Palliative Care 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. Annual 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 Medical Director/Physician/NP Name Email Social Worker Name Email Bereavement Coordinator Name Email Volunteer Coordinator Name Email Spiritual Care Coordinator Name Email Biller Name Email QAPI Coordinator Name Email Other StaffPlease 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 Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name
