Your Name:*

First Last

Your Email:*

Your Phone Number:*

Facility Type:*

Nursing Home
Assisted Living

# Nursing Home Beds:*

# Assisted Living Beds:*

Distribution of Beds

# Medicare Beds:

# Non-Medicare Beds:

# Alzheimer's Beds:

# Other beds:

Facility Information

Facility/Community Name:*

Facility Address:*

Street Address Address Line 2 City State ZIP Code

Facility Phone Number:*

Facility Fax:*

If no Fax Number, please enter 10 zeros

Facility Payment Types*

Select All
Medicare
Medicaid
Private Pay

Facility Website:*

If no website, please enter 'No Website'

Primary Contact Name (Administrator, Executive Director):*

First Last

Primary Contact Title:

NHA
ALA
Executive Director
NHA/ALA

This will help CHCA send more relevant communications to the Facilities Primary Contact

Primary Contact Email:*

Primary Contact Phone Number:*

Billing Contact Name:*

First Last

Billing Contact Email:*

Billing Contact Phone Number:*

Operating/Management Company Name:*

If no Operating/Management Company, please list as Independent

Operating/Management Company Phone Number:*

Operating/Management Company Contact Person Name:

First Last

Operating/Management Company Contact Person Email:

Operating/Management Company Address:

Street Address Address Line 2 City State ZIP Code

Operating/Management Company Fax:

Facility Owner:

If different from management company

Facility Owner Phone Number:

Facility Owner Contact Person Name:

First Last

Facility Owner Contact Person Phone Number:

Facility Owner Contact Person Email:

Contact Information Spreadsheet Upload

Accepted file types: doc, xls, ppt, pdf, Max. file size: 21 MB.

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: $72.75 per bed

Assisted Living Residences
All Beds: $34.27 per bed ($750 Annual Minimum)

Payment Options:*

I 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 September

We 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.

Facility Membership Application

Distribution of Beds

Facility Information

Dues Structure

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