Professional Provider Renew Membership Renewal Membership Dues Fees: Dues Calculation = $300 + $4 per Patient Admissions in Previous Calendar YearYou 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.Provider 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 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 - for inclusion on website directory)Counties served: (Please list all that apply - for inclusion on website directory)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 Total $0.00 Credit CardCard Details Cardholder Name
