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Facility Membership Application

Your Name: * Required
First Last
Your Email: * Required
Your Phone Number: * Required
Facility Type: * Required
- Nursing Home
- Assisted Living
# Nursing Home Beds: * Required
# Assisted Living Beds: * Required
Distribution of Beds
# Medicare Beds:
# Non-Medicare Beds:
# Alzheimer's Beds:
# Other beds:
Facility Information
Facility/Community Name: * Required
Facility Address: * Required
Street Address Address Line 2 City State ZIP Code
Facility Phone Number: * Required
Facility Fax: * Required

If no Fax Number, please enter 10 zeros
Options:
- 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 Contact
Primary Contact Email: * Required
Primary Contact Phone Number: * Required
Billing Contact Name: * Required
First Last
Billing Contact Email: * Required
Billing Contact Phone Number: * Required
Operating/Management Company Name: * Required

If no Operating/Management Company, please list as Independent
Operating/Management Company Phone Number: * Required
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
Payment Options: * Required
- 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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Upcoming Events

5

Oct

26

2021

Essentials of a Nursing Home Administrator (Day One)
Tue 10/26/20219am5pm

Virtual Training

Published by: ahoward

Oct

26

2021

District II
Tue 10/26/202112pm1pm

Virtual Meeting

Published by: ahoward

Oct

27

2021

The Essentials of a Nursing Home Administrator (Day Two)
Wed 10/27/20219am5pm

Virtual Training

Published by: ahoward

Oct

27

2021

District I
Wed 10/27/202110:30am12pm

Virtual Meeting

Published by: ahoward

Oct

27

2021

Bi-Weekly Membership
Wed 10/27/202112pm1pm

Virtual Meeting

Published by: ahoward

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