Membership InformationInnovate. Advocate. Collaborate. Please enable JavaScript in your browser to complete this form. - Step 1 of 5Thank you! Now that you've completed the initial membership criteria, please continue the member application process by providing the following details. You will be contacted regarding your application once you have completed this form. Fields marked (*) are required.General InformationName of Program *Main Office Address *Year Founded *TitleMr.Mrs.Ms.Dr.First Name *Last Name *Email *Name of President / CEOPlease include a short biography of CEOBrief History and Mission of ProgramWebsite / URL *PSR on line 9 of current 990 tax form *Innovative programs in placeAre you part of a larger health system? YesNoName of Health SystemService AreaName(s) of County(ies) Covered *State(s) Covered *NextLast Year's Census NumbersTotal number of patients served last year? *Hospice ADC last year? *Total Number of Palliative Care Patients last year (if applicable)? *PreviousNextStaffingNumber of Full Time Employees *Number of Part Time Employees *OtherPreviousNextQualityAre you currently NCQA/Joint Commission/etc accedited/certified?YesNoName of OrganizationPreviousNextEMR Vendor *CommentSubmitAbout UsCurrent MembersMembership InformationVendor ProgramsFind Your NPHI Trusted Not-for-Profit Provider: NPHI Provider Locator 844-GET-NPHI (844-438-6744)
