Fremont

Toll free: (866) 306-1961
FAX:  (231) 924-4882 

Email: membership@narhc.org           
Web: www.narhc.org

Membership Application

Why join?  Joining the NARHC is an investment in the future of the RHC program.  NARHC advocates at the federal and state level for policies, grant opportunities, and legislation that benefit Rural Health Clinics and the patients they serve.  Through conferences, educational workshops, teleconferences, list serve forum, web site, legislative updates, and quarterly newsletters NARHC gets you the most up-to-date information.

SECTION A:  GENERAL INFORMATION

1.	Member Name:
2.	Name of Organization:
3.	Clinic Name               (if applicable):
4.	Complete Mailing Address:
5.	Phone: Fax:
6.	E-mail Address:
7.	Membership Status:	r         Renewal                      r         New Member
8.	Type of Membership:	r         New RHC Clinic – less than two years r         Independent RHC r         Provider-based RHC r         Governmental/Association (non-voting) r         Corporate (non-voting) r         Consultant
9.	Dues:	Mail your application & payment to: NARHC, 2 East Main Street, Fremont, MI 49412
	r         New RHC Clinic                                     $200.00                                   r         Independent RHC                                   $450.00 r         Provider-based RHC                              $450.00 r         Additional Clinics                                    $115.00 for ea. add. clinic r         Governmental/Association                     $400.00 r                  Corporate                                               $550.00 r                  Consultant                                              $550.00
	Method of Payment: r        Check r                  Credit Card (Visa or Master Card Only!)		Credit Card: Credit Card Number: ____________________________________ Expiration Date: _________Three digit security code: __________ Name on Card: ________________________________________ Credit Card Billing Address:_______________________________
	Total Amount Paid		$

The following Section is important!  It allows NARHC to accurately represent its membership on key policy and legislative issues.  All information will be kept confidential and no clinic specific information will be released.  If your clinic is part of an Affiliation Network, please copy this page and complete a Section B for each rural health clinic affiliate member.

SECTION B:  CLINIC INFORMATION

1.	Clinic Name:
2.	Clinic Address:
3.	Clinic Contact No.:	Tele:			Fax:		E-mail:
4.	Clinic Specialty:		Sub-Specialty:
5.	Date of Initial RHC Certification:
6.	Current Medicare all-inclusive rate:			$                     /encounter
7.	Annual Encounters (total patient encounters from most recent cost-report
	No. of Medicare encounters:				No. of Medicaid encounters:
8.	How many days per week is your RHC open for patient care?
9.	Please indicate the type of providers by health profession and full time/part time status providing care at the RHC:
	Professional Type	Specialty (if applicable)				Number of Full Time Equivalents (FTEs)
	Physician
	Physician Assistant
	Nurse Practitioner
	Certified Nurse Midwife
	Clinical Psychologist
	Social Worker
	Chiropractor
10.	What is the population (round to the nearest 1,000) of the town where the RHC is located?
11.	What is your best estimate of the population of the RHC’s service area?
12.	Do you participate with a Medicare HMO or PPO plan?  r Yes        r No
13.	Do you participate with a State sponsored Medicaid HMO plan? r Yes       r No
14.	Does your clinic accept new patients?           r Yes  r No
15.	What percentage of the RHC’s patient population is uninsured?

Release of Information:

NARHC’s mailing list has been requested for purchase by third parties. Our mailing list consists of members, listserve requests, purchased CMS list and participants from conferences.  NARHC has the right to refuse the sale of this list upon their discretion.  Because we value your opinion as a member, please indicate below your desire.

r Yes, I would like my contact information passed along to valuable third parties.

r No, I do not want my contact information passed along.  

Note: If no box is checked, NARHC will assume it is fine to release your information.