Membership Application/Renewal Survey

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* 1. Is this application for new membership or renewal?

New

Renewal

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* 2. Hospice Name

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* 3. Other names used by your hospice:

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* 4. What is your primary hospice license number?

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* 5. Mailing Address:

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* 6. Organization Main Phone #:

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* 7. Does your hospice currently operate an inpatient unit?

Yes

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* 8. Does your hospice currently provide palliative care services? (check all that apply)

Community-based services

Inpatient via contractual arrangement outside organization

Inpatient affiliated with own organization

Outpatient clinic

None

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* 9. Does your organization have a home health license?

Yes, in North Carolina

Yes, in South Carolina

Yes, in both NC and SC

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* 10. What are your billing mechanisms? (check all that apply)

Medicare Part A&B

Medicaid

Private payer

Foundation

Other (please specify)

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* 11. Does your organization provide pediatric care?

Yes

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* 12. Does your organization provide hospice and/or palliative care in nursing homes?

Yes

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* 13. Is your organization affiliated with any health system or hospital?

Yes

If so, which one?

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* 14. Is your hospice organization currently accredited?

Accreditation Commission for Health Care (ACHC)

Community Health Accreditation Partner (CHAP)

Joint Commission

Not Accredited

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* 15. Is your organization a partner with NHPCO "We Honor Veterans" program?

Yes

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* 16. Is your organization a member of any other healthcare associations?

Yes

If so, which ones?

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* 17. What is the tax status of your hospice organization?

For Profit

Nonprofit

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* 18. Please list all counties you serve. (through any licensed offices)

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* 19. What state issues your primary license?

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* 20. Does your organization maintain multiple locations from which hospice services are provided?

Yes

If yes, please provide the locations and addresses.

Hospice CEO/Executive Director Information:

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* 21. Full name and title:

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* 22. Email:

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* 23. Phone #:

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* 24. Credentials:

MSW

CPA

MBA

MSN

PhD

BSW

Other (please specify)

Billing Information:

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* 25. Billing contact full name and title:

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* 26. Email:

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* 27. Phone #:

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* 28. Would you prefer to be billed annually or quarterly?

Quarterly

Annually

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* 1. Is this application for new membership or renewal?

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* 2. Hospice Name

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* 3. Other names used by your hospice:

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* 4. What is your primary hospice license number?

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* 5. Mailing Address:

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* 6. Organization Main Phone #:

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* 7. Does your hospice currently operate an inpatient unit?

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* 8. Does your hospice currently provide palliative care services? (check all that apply)

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* 9. Does your organization have a home health license?

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* 10. What are your billing mechanisms? (check all that apply)

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* 11. Does your organization provide pediatric care?

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* 12. Does your organization provide hospice and/or palliative care in nursing homes?

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* 13. Is your organization affiliated with any health system or hospital?

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* 14. Is your hospice organization currently accredited?

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* 15. Is your organization a partner with NHPCO "We Honor Veterans" program?

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* 16. Is your organization a member of any other healthcare associations?

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* 17. What is the tax status of your hospice organization?

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* 18. Please list all counties you serve. (through any licensed offices)

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* 19. What state issues your primary license?

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* 20. Does your organization maintain multiple locations from which hospice services are provided?

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* 21. Full name and title:

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* 22. Email:

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* 23. Phone #:

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* 24. Credentials:

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* 25. Billing contact full name and title:

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* 26. Email:

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* 27. Phone #:

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* 28. Would you prefer to be billed annually or quarterly?

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* 29. Total patient days of care for all NC and SC hospice locations from 10.01.2017 - 09.30.2018?

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* 30. Name of person who completed this application:

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* 31. Email address for person who completed this application: