Membership Info

Facility Name: *

Address:

City, State Zip:

Phone: *

E-mail:

Fax:

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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Residential Care Beds:

(Level 3)

(Level 4)

ERC Medicaid Waiver

VA Approved

ACCS Certified

Accept SSI

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

Wheelchair Equipped Van

Hospice Program

Security Alert System

Palliative Care

Respite Care

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: