Facility Membership Application Your Name: * Required First Last Your Email: * Required Your Phone Number: * RequiredFacility Type: * Required Nursing Home Assisted Living # Nursing Home Beds: * Required# Assisted Living Beds: * RequiredDistribution of Beds# Medicare Beds:# Non-Medicare Beds:# Alzheimer's Beds:# Other beds:Facility InformationFacility/Community Name: * RequiredFacility Address: * Required 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 Facility Phone Number: * RequiredFacility Fax: * RequiredIf no Fax Number, please enter 10 zerosOptions: Licensed Units For Profit Multifacility Medicare/Medicaid Certified Not For Profit Independent Facility Payment Types * Required Select All Medicare Medicaid Private Pay Facility Website: - enter a valid website URL for example https://www.google.com * Required If no website, please enter 'No Website'Primary Contact Name (Administrator, Executive Director): * Required First Last Primary Contact Title: NHA ALA Executive Director NHA/ALA This will help CHCA send more relevant communications to the Facilities Primary ContactPrimary Contact Email: * Required Primary Contact Phone Number: * RequiredBilling Contact Name: * Required First Last Billing Contact Email: * Required Billing Contact Phone Number: * RequiredOperating/Management Company Name: * RequiredIf no Operating/Management Company, please list as Independent Operating/Management Company Phone Number: * RequiredOperating/Management Company Contact Person Name: First Last Operating/Management Company Contact Person Email: Operating/Management Company 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 Operating/Management Company Fax:Facility Owner:If different from management companyFacility Owner Phone Number:Facility Owner Contact Person Name: First Last Facility Owner Contact Person Phone Number:Facility Owner Contact Person Email: Contact Information Spreadsheet UploadAccepted file types: doc, xls, ppt, pdf.Please fill out the Contact Information Spreadsheet located at the bottom of this form. This will allow CHCA to send communications directly to your staff upon membership approval. If form does not appear along the bottom of your screen, please check your computers downloads folder.Dues Structure Licensed NCF Beds All Beds: $69.55 per bed Assisted Living Residences All Beds: $31.65 per bedPayment Options: * RequiredI will pay my Facility dues in nine (9) monthly installments due the first day of each month, beginning January 1st.I will pay my Facility dues in FULL prior to December 31st. I will receive a 3% discount off my total dues.I will pay my Facility dues in four (4) quarterly installments due the first day of January, April, July and SeptemberWe will contact you for your payment. Please mail application with check attached to: Colorado Health Care Association 4100 E. Mississippi Ave. Suite 925 Glendale, CO 80246 to the attention of Director of Finance. CHCA New Facility Member Contact Persons Upload Template
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