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 InformationFacility/Community Name:* Facility Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Facility Phone Number:* Facility Fax:* If no Fax Number, please enter 10 zerosOptions: 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 ContactPrimary 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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, 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. Δ CHCA New Facility Member Contact Persons Upload Template
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