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Nursing Home Membership Application
Membership – Nursing Home
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Email:
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Fax:
Federal Medicare Provider Number:
VHCA Designated Voting Rep.:
Owner/Affiliation:
Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Website:
Tax Status:
For-Profit
Non-Profit
Hospital Based
Year Established:
# Currently on Staff (all dept.):
Nursing Facility Beds: Level 1
Nursing Facility Beds: Level 2
Residential Care Beds: Level 3
Residential Care Beds: Level 4
Additional Info:
Medicare Certified
Medicaid Certified
ERC Waiver Beds
JCAHO Accredited
VA Approved
Services Provided:
Alzheimer/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
(please check all that apply)
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:
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