Professional Provider Membership

Below you can enter your program information, staff contacts information and pay securely using a credit card. If you prefer to pay by check, you can download the PDF membership packet HERE, complete the forms and submit with payment by US Mail to OHPCA at P. O. Box 592, Marylhurst, OR 97036.

PROFESSIONAL PROVIDER MEMBER DUES
Professional Provider Members are corporations, agencies, or divisions who provide hospice and/or palliative care under a single CMS Provider Identification Number (Including identified multiple locations). Dues Calculation: flat fee of $400 + $5 per patient admission for year 2022. All fields with a red asterisk are required. Questions? Please email Meg at mccauley@oregonhospice.org or call/text 503.890.7027.
Provider Member Program Details
Information in this section reflects what will appear on your listing in OHPCA's website Directory.
Program Name*

Please enter your Program Name as you'd like it to appear on the OHPCA website directory.
Please click on the services your program provides from the menu (multiple selections OK):
- Hospice
- Inpatient Hospice
- Palliative Care
- Inpatient Palliative Care
- Other
If you chose "other" above, please describe.
Program Address*
Street Address Address Line 2 City State ZIP Code

Please enter your Program Address as you'd like it to appear on the OHPCA website directory.
Program Telephone*
Please enter your Program Telephone Number as you'd like it to appear on the OHPCA website directory.
Website
Cities served: (Please list all that apply.)
Please list the cities your Program serves so consumers can search the OHPCA website directory by City and find your program. If there are too many to list here, you can email your list to mccauley@oregonhospice.org.
Counties served: (Please list all that apply.)
Please list the counties your Program serves so consumers can search the OHPCA website directory by County and find your program.
OWNERSHIP*
- Hospice corporate chain
- Managed care/HMO
- Integrated healthcare system
- Continuing care retirement community
- Independent
- Division of a prison
Corporate name/affiliation/ownership and location (city/state):
Staff Contacts
Please include program staff information so that we can add them to our monthly networking distribution lists.
Program Director/Administrator*
First Last Credentials/Title
Program Director/Administrator E-mail*
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Primary Contact (if different from above)
First Last Credentials/Title
Primary Contact Email
Enter Email Confirm Email
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Medical Director/Physician/Nurse Practitioner*
First Last Credentials/Title
Medical Director/Physician/Nurse Practitioner Email*
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
QAPI Coordinator*
First Last Credentials/Title
QAPI Coordinator E-mail*
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Volunteer Coordinator*
First Last Credentials/Title
Volunteer Coordinator E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Clinical Contact*
First Last Credentials/Title
Clinical Contact E-mail*
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Biller
First Last Credentials/Title
Biller E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Social Worker
First Last Credentials/Title
Social Worker E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Bereavement Coordinator
First Last Credentials/Title
Bereavement Coordinator E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
PR/Marketing/Development Coordinator
First Last Credentials/Title
If you do not have someone in this role at this time, please insert Program Director name.
PR/Marketing/Development Coordinator E-mail

If you do not have someone in this role at this time, please insert Program Director email.
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Spiritual Care Coordinator
First Last Credentials/Title
Spiritual Care Coordinator E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Other Staff
First Last Credentials/Title
To add more staff to our distribution lists, please email mccauley@oregonhospice.org with the names, titles, email addresses and which networking lists they would like to be added to.
Other Staff E-mail
Optional - Please add this person to the following distribution lists for networking:
- Select All
- QAPI/Regulatory
- Inpatient Directors/Managers Monthly Networking (only for those with Inpatient programs)
- Public Policy
- Education/Conference Planning
- Medical Directors, Physicians, NPs
- Palliative Care Networking Interest
- PR/Marketing/Development
- Volunteer Coordinators
- Billers
- Pediatric Palliative Care Networking Interest
Billing Information
Name of person completing this form:*
First Last
Email for payment receipt:*
Enter Email Confirm Email

Please include the email address of the person who will receive this receipt of payment.
Program Flat Fee*
Price:
Number of patients admitted in 2022 Quantity*
Price: $5.00
$5 per patient admissions in 2022
Total
$0.00
Credit Card
Card Details
Cardholder Name

Professional Provider Membership

PROFESSIONAL PROVIDER MEMBER DUES

Provider Member Program Details

Staff Contacts

Billing Information