Provider Membership Application - Illinois Hospice and Palliative Care Organization (IL-HPCO)

Member Information

Name of Organization*

Address*

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

Phone*

Fax

Email*

Organization Information

Name of CEO/Executive Director*

First Last

Title*

Business Address*

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

Business Phone*

Business Fax

Business Email*

For Profit/Not for Profit?*

List counties you serve which will be used for our Consumer Hospice Locator*

Identify a portion of a county with an asterisk*

Terms*

As a member of IL-HPCO, I consent to the user of my e-mail address for receipt of organization notices and newsletters.

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

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

Name	Title	Phone	Email

Member Dues

CURRENT Provider Member Dues *

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 *

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 Amount to be Billed

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

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Name

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