Facility Membership Application

Your Name: *

First Last

Your Email: *

Facility Type: *

Nursing Home
Assisted Living

# Nursing Home Beds *

# Assisted Living Beds *

Options:

Licensed Units
For Profit
Multifacility
Medicare/Medicaid Certified
Not For Profit
Independent

Distribution of Beds

# Medicare Beds:

# Non-Medicare Beds:

# Alzheimer's Beds:

# Other beds:

Facility Information

Facility/Community Name: *

Address: *

Street Address Address Line 2 City State ZIP Code

Phone: *

Fax:

Email: *

Website:

Contact Name (Administrator, Executive Director): *

First Last

Operating/Management Company Name:

Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Fax:

Email:

Ownership:

Dues Structure

Licensed NCF Beds
All Beds: $69.55 per bed

Assisted Living Residences
All Beds: $31.65 per bed

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, 225 E. 16th Avenue, Ste. 1100 Denver, CO 80203 to the attention of Director of Finance.

Distribution of Beds

Facility Information

Dues Structure

Upcoming Events

Nurse Executive Council (NEC)
Thu 7/9/20208:30am10am

Executive View of Colorado’s Pay Equity Law
Thu 7/9/20201pm2:30pm

Medicaid Provider Collaborative Committee
Tue 7/21/20201pm2:30pm

Associate Member Spotlight

Distribution of Beds

Facility Information

Dues Structure

Upcoming Events

Nurse Executive Council (NEC)Thu 7/9/20208:30am10am

Executive View of Colorado’s Pay Equity LawThu 7/9/20201pm2:30pm

Medicaid Provider Collaborative CommitteeTue 7/21/20201pm2:30pm

Associate Member Spotlight

Nurse Executive Council (NEC)
Thu 7/9/20208:30am10am

Executive View of Colorado’s Pay Equity Law
Thu 7/9/20201pm2:30pm

Medicaid Provider Collaborative Committee
Tue 7/21/20201pm2:30pm