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Facility Membership Application

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
Options:
- Licensed Units
- For Profit
- Multifacility
- Medicare/Medicaid Certified
- Not For Profit
- Independent
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: $69.55 per bed

Assisted Living Residences
All Beds: $31.65 per bed ($500 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.

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CHCA New Facility Member Contact Persons Upload Template

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Consumers
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Upcoming Events

Feb

8

2023

H/R Staff Retention Training Day 2Wed 2/8/20237am8am

Virtual Meeting

Member: $50; Non Member: $150

Published by: ahoward

Feb

9

2023

Nutritional Professionals CouncilThu 2/9/20232pm2pm

Virtual Meeting

Published by: ahoward

Feb

14

2023

2023 Lead with a Laser Focus: Leveraging QAPI and Your Facility AssessmentTue 2/14/202310am12pm

TBA

Member: $50; Non-Member: $150

Published by: ahoward

Feb

14

2023

Medicaid Provider Collaborative CommitteeTue 2/14/20231pm2:30pm

Virtual Meeting

Published by: ahoward

Feb

14

2023

Quality Initiatives & Leadership CouncilTue 2/14/20232pm3pm

Virtual Meeting

Published by: ahoward

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