Any organization doing business in Arizona, including not-for-profit, investor-owned, and government-operated entities, that provides direct patient care services to people, provides health insurance or coverage, or offers consumer support to the healthcare community as a substantial part of its activities is eligible to become a healthcare member.
Section I

Question Title

* 1. Name of organization

Question Title

* 2. Owned by

Question Title

* 3. Operated by

Question Title

* 4. Street address

Question Title

* 5. Mailing address (if different from street address)

Question Title

* 6. City, state, zip code

Question Title

* 7. Main line phone number

Question Title

* 8. Organization's website

Question Title

* 9. Name of chief executive officer/principal

Question Title

* 10. Title of chief executive officer/principal

Question Title

* 11. Chief executive officer / principal direct phone number

Question Title

* 12. Chief executive officer/principal email address

Question Title

* 13. Name of Accounts Payable contact

Question Title

* 14. Email address of Accounts Payable contact.

Question Title

* 15. Organization's Social Media

Section II

Question Title

* 16. Describe the organization’s purpose and nature of services provided

Question Title

* 17. How did you hear about us?

Section III - All applications for healthcare membership must be reviewed by AzHHA’s president and chief executive officer. AzHHA may, at the sole discretion of its Board of Directors, grant or deny any application for membership and may censure, suspend or expel any member, in conformance with AzHHA’s bylaws.

Question Title

* 18. Electronically sign this application by typing in the full name of the person submitting this application

Question Title

* 19. Title of person submitting this application

Question Title

* 20. Date

Date

T