New RHC Member Application

If you have more than 5 Rural Health Clinics in your organization, please continue using the form linked here instead.

If you are a Non-RHC, please use this form.

*Required field(s) are indicated by an .**
PARENT ORGANIZATION & BILLING CONTACT INFORMATION If you are an independent clinic, please enter your clinic as both the parent organization and clinic #1.
* Person Completing This Application
* Email
* Phone Number	Numeric Only
* Organization Name
Website
* Primary Contact Name
* Primary Contact Title
* Primary Contact Email
* Primary Contact Phone Number	Numeric Only
* Billing Address
* Billing City
* Billing State
* Billing Zip Code
CLINIC INFORMATION CLINIC #1
* Clinic Type
* Clinic Name
* CMS Provider Number (CCN)	Leave blank if pending
* Clinic Physical Address
* City
* State
* Zip Code
* Clinic Phone Number	Numeric Only
* Clinic Contact Full Name
* Title
* Work Email
Select to Receive Member Benefits
If you do not have additional clinics, proceed to the bottom of the page. CLINIC #2
Clinic Type
Clinic Name
CMS Provider Number (CCN)	Leave blank if pending
Clinic Physical Address
City
State
Zip Code
Clinic Phone Number	Numeric Only
Clinic Contact Full Name
Title
Work Email
Select to Receive Member Benefits
If you do not have additional clinics, proceed to the bottom of the page. CLINIC #3
Clinic Type
Clinic Name
CMS Provider Number (CCN)	Leave blank if pending
Clinic Physical Address
City
State
Zip Code
Clinic Phone Number	Numeric Only
Clinic Contact Full Name
Title
Work Email
Select to Receive Member Benefits
If you do not have additional clinics, proceed to the bottom of the page. CLINIC #4
Clinic Type
Clinic Name
CMS Provider Number (CCN)	Leave blank if pending
Clinic Physical Address
City
State
Zip Code
Clinic Phone Number	Numeric Only
Clinic Contact Full Name
Title
Work Email
Select to Receive Member Benefits
If you do not have additional clinics, proceed to the bottom of the page. CLINIC #5
Clinic Type
Clinic Name
CMS Provider Number (CCN)
Clinic Physical Address
City
State
Zip Code
Clinic Phone Number	Numeric Only
Clinic Contact Full Name
Title
Work Email
Select to Receive Member Benefits
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