Provider Membership Application

Submit your application by completing the form below:

  • Member Information

  • Organization Information

  • Identify a portion of a county with an asterisk*
  • Please use the +/- buttons to add or remove members
    NameTitlePhoneEmail 
  • Member Dues

  • Please enter the number of Admissions/Readmissions as the quantity.
    $7.00 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, and you will need to contact IL HPCO at pcramer@il-hpco.org, or call 847.441.7200

    Price: $7.00 Quantity:
  • Please enter the number of Admissions/Readmissions as the quantity.
    $7.00 per admission, with a one-time 25% 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: $5.25 Quantity:
  • $0.00
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