Provider Membership Application

Submit your application by completing the form below:

If you are an existing provider looking to renew membership as is, please fill out the Provider Renewal Form.

Member Information

Name of Organization(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Fax

Organization Information

Name of CEO/Executive Director(Required)

First Last

Title(Required)

Business Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Business Phone(Required)

Business Fax

Business Email(Required)

For Profit/Not for Profit?(Required)

For Profit

Not for Profit

List countries you serve which will be used for our Consumer Hospice Locator(Required)

Identify a portion of a country with an asterisk*

For others to receive IL-HPCO updates (mailing, e-news, and special announcements) in addition to the contact above, enter staff information here

Name

Title

Phone

Please use the +/- buttons to add or remove staff members

Member Dues

What best describes your membership?(Required)

I am a current provider and need to renew our membership AND add new seats.

I am a NEW provider that needs to join.

Note: The minimum membership dues for new hospices is $200. Please ensure you reach the minimum amount to submit payment.

CURRENT Provider Member Dues (Required)

Please enter the number of Admissions/Readmissions as the quantity.
$7.50 per admission for previous year. Dues period is from January 1st through December 31st. IL HPCO is basing dues on previous year admissions, unless your admissions have declined, then we honor a lower rate for dues billing.

Price: $7.50

NEW Provider Member Dues (Required)

Please enter the number of Admissions/Readmissions as the quantity.
$5.00 per admission, with a one-time discount for new members. If provider has multiple provider numbers or program sites, fee is assessed on all admission in the state of IL. Fees are capped at $20,000.

Price: $5.00

Please consider an additional contribution to support the work of IL-HPCO, a 501c (3) organization.

Total

Credit Card