Professional Provider Membership Enter Your Details Below to Create Your AccountYou will receive via email a confirmation and receipt of your payment. If you do not see your receipt, please check your spam or junk mail folder. You may also email mccauley@oregonhospice.org or call 503.890.7027 for donation/payment troubleshooting.Name* First Last Username* Email* Enter Email Confirm Email Password* Enter Password Confirm Password Strength indicator Membership Dues FeesDues Calculation: $300 + $4 per patient admissions in 2021Provider Member Category*Inpatient HospiceHospice Program OnlyHospice + Palliative Care ProgramPalliative Care Program OnlyProfessional Provider Member Fee* Price: Hospice Program Only or Hospice + Palliative Care Program* Price: Number of patients admitted in 2021 Quantity* Price: $4.00 Quantity $4 per patient admissions in 2021Product NameHiddenNumber of Oregon hospice/palliative care patients admitted in 2021Membership Fee Total $0.00 Provider Member Program DetailsProgram Name* Type of program* Inpatient Hospice Program Hospice Program Only Hospice + Palliative Care Program Palliative Care Program Only Program Mailing 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 Program Telephone*Website Cities served: (Please list all that apply.)Counties served: (Please list all that apply.)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 ContactsPlease include program staff information so that we can add them to our monthly networking distribution lists.Program Director/Administrator* First Last Program Director/Administrator E-mail* Optional - Please add this person to the following distribution lists: Select All Inpatient Directors/Managers Monthly Networking Public Policy Education/Conference Planning Directors/Administrators are automatically added to OHPCA's Provider Member, monthly Program Directors & Administrators networking and monthly QAPI/Regulatory networking distribution lists.Primary Contact (if different from above) First Last Primary Contact Email Enter Email Confirm Email Optional - Please add this person to the following distribution lists: Select All Inpatient Directors/Managers Monthly Networking Public Policy Education/Conference Planning Primary Contacts are automatically added to OHPCA's Provider Member, monthly Program Directors & Administrators networking and monthly QAPI/Regulatory networking distribution lists.Hospice Physician/Nurse Practitioner First Last Hospice Physician/Nurse Practitioner Email Optional - Please add this person to the following distribution lists: Select All QAPI/Regulatory Public Policy Education/Conference Planning Hospice Physicians & Nurse Practitioners are automatically added to OHPCA's monthly Hospice Physicians & Nurse Practitioners Networking distribution list.QAPI Coordinator First Last QAPI Coordinator E-mail Optional - Please add this person to the following distribution lists: Select All Public Policy Education/Conference Planning QAPI Coordinators are automatically added to OHPCA's monthly QAPI/Regulatory Networking distribution list.Volunteer Coordinator First Last Volunteer Coordinator E-mail Optional - Please add this person to the following distribution lists: Select All QAPI/Regulatory Public Policy Education/Conference Planning Volunteer Coordinators are automatically added to OHPCA's monthly Volunteer Coordinators Networking distribution list.Hospice Biller First Last Hospice Biller E-mail Optional - Please add this person to the following distribution lists: Select All QAPI/Regulatory Public Policy Education/Conference Planning Clinical Contact First Last Clinical Contact E-mail Optional - Please add this person to the following distribution lists: Select All QAPI/Regulatory Public Policy Education/Conference Planning Social Worker First Last Social Worker E-mail Optional - Please add this person to the following distribution lists: QAPI/Regulatory Public Policy Education/Conference Planning Bereavement Coordinator First Last Bereavement Coordinator E-mail Optional - Please add this person to the following distribution lists: QAPI/Regulatory Public Policy Education/Conference Planning Spiritual Care Coordinator First Last Spiritual Care Coordinator E-mail Optional - Please add this person to the following distribution lists: QAPI/Regulatory Public Policy Education/Conference Planning Other Staff First Last Other Staff Title Other Staff E-mail Optional - Please add this person to the following distribution lists: QAPI/Regulatory Public Policy Education/Conference Planning Billing InformationName* First Last Email* Enter Email Confirm Email Billing 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 Credit CardCard Details Cardholder Name Total $0.00
