Membership Info

Facility Name: *

Address:

City, State Zip:

Phone: *

E-mail:

Fax:

Federal Medicare Provider Number:

VHCA Designated Voting Rep.:

Owner/Affiliation:

Address:

City, State Zip:

Website:

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Tax Status:

Select... For-Profit Not-For-Profit Hospital Based

Year Established:

# Currently on Staff (all dept.):

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Nursing Facility Beds:

(Level 1)

(Level 2)

Residential Care Beds:

(Level 3)

(Level 4)

Medicare Certified

Medicaid Certified

ERC Waiver Beds

JCAHO Accredited

VA Approved

Rates for Private Pay as of 11-1-06:

Private Room:

Semi-Private:

Services provided (please check all that apply and list any additional services):

Alzheimer or other Dementia

Managed Health Care

Out Patient Therapy

Sub Acute Care/Rehab

Wheelchair Equipped Van

Security Alert System

Hospice Program

Occupational Therapy

Respiratory Therapy

Restorative Therapy

Speech Therapy

On Site Adult Day Care

IV Therapy

Palliative Care

Wound Care

Respite Care

Physical Therapy

Department Heads:

Administrator

Name:

Email:

Director of Nursing

Name:

Email:

Activity Director

Name:

Email:

Dietary Director

Name:

Email:

Social Services Director

Name:

Email:

Maintenance Director

Name:

Email:

Medical Director

Name:

Email:

Comments or Questions: