Professional Provider Renew Membership PROFESSIONAL PROVIDER MEMBER DUESProfessional 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 DetailsInformation 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 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 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 ContactsPlease 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 InformationName 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 Quantity $5 per patient admissions in 2022Total $0.00 Credit CardCard Details Cardholder Name
