Instructions

Please copy this page and complete one for each office of each of your organizations (e.g., a LHCSA, CHHA). If you are a franchisee, list only the office of your franchise. It is important to complete this form for all branch offices for two reasons:

1. Branch offices listed will be entered in HCP's database system which determines eligibility for HCP membership benefits.

2. The information included below will be made available to referral sources, and will be listed in the database of providers on HCP's website.

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* Organization

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* d/b/a

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* Year Established

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* Branch Information

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* Operating Certificate #

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* Permanent Facility Identifer (PFI), if applicable:

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* Director of Patient Services

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* E-Mail

Corporate Type (check all that apply)

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* Proprietary

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* Not for Profit

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* Corporate structure (check one)

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* Is this office a member of an HCP Chapter?

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* If yes, which Chapter(s)

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* What type of office is listed on this form?

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* What counties are served by this office? (check all that apply)

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* What services are provided through this office? (check all that apply)

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* What payment sources are accepted by this office? (check all that apply)

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* Is this office accredited?

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* Which accrediting body?

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