Associate Provider Membership Application

HASC Associate Provider Membership offers you a direct connection with CEOs and other decision-makers who need fresh ideas and solutions. You can become a trusted hospital partner and present your organization and services as valuable resources to help tackle real challenges.

To apply for associate provider membership, please fill out and submit the form below. For any questions, contact [email protected].

Associate Provider Membership Application

Please note: Annual membership dues will be calculated based on the information provided.

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Section One: Organization Information

Organization name*

Mailing address*

City*

State*

Zip*

Website*

Phone*

Federal tax ID number*

Date founded*

Section Two: Directory Information (list executive team members)

Primary contact/applicant's name:*

First name Last name

Title*

Email*

Phone*

Chief executive officer*

First name Last name

Title*

Email*

Phone*

Additional contact

First name Last name

Title

Phone

Additional contact

First name Last name

Title

Phone

Section Three: Membership Classification

Please select the ONE category that best describes your organization’s primary services.

Group 1

Inpatient Facilities: Organizations admitting patients to a licensed bed for extended periods and providing continuous 24-hour care (e.g., skilled nursing facilities, LTACs, psychiatric health facilities, inpatient rehabilitation facilities, specialized limited-service hospitals, inpatient hospice providers)

HCAI ID

Please provide HCAI ID

Licensed beds

Number of licensed beds

Group 2

Outpatient/Ambulatory Facilities: Organizations providing same-day diagnostic, preventive or interventional care without an overnight stay (e.g., primary care clinics, ambulatory surgery centers, urgent care centers, medical groups, physician organizations)

Full-time employees

Please provide number of full-time employees

Group 3

Other Clinical Continuum Providers: Specialized organizations offering essential nonresidential services supporting the broader health care system (e.g., organ procurement, community blood banks, specialized contractual service providers and agencies)

Section Four: Authorization and Agreement

HASC Associate Provider Membership is a commitment to a shared future in health care. You’ll gain the connections and resources you need to grow your organization and make a lasting impact as you partner with hospitals to better serve our communities.

Please type your signature*

By typing your name below, you acknowledge and agree that it constitutes your electronic signature and consent to the certification and consent described above. This electronic signature is legally binding and has the same force and effect as a handwritten signature, to the extent permitted by law.

Date*

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