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Organization Membership
Organization Member Application Form
Membership Terms and Conditions
All beds, units, services must be included in membership. IHCA, ICAL, ICHC bylaws state “it shall be expected that any member who owns and operates more than one of the above services shall have 100% of those facilities/services in membership of the IHCA, ICAL, and ICHC.”
Payment Information
Organization members will receive an invoice for their membership dues. A member may voluntarily withdraw from membership in the association with 30-day written notice to info@iowahealthcare.org. Upon voluntary termination, dues shall not be refunded. Termination does not reduce or forgive any debt owed at the time of termination.
Organization Name
*
Required
Organization Contact Name
First
Last
Email
Phone
Address
Street Address
Address Line 2
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Billing Contact Name
*
Required
First
Last
Billing Contact Title
*
Required
Billing Contact Email
*
Required
Billing Address (if different from above)
Street Address
Address Line 2
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
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
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
Billing Preference
*
Required
Annual
Quarterly
Semi-Annual
Website
Ownership Type:
*
Required
Proprietary
Non-Proprietary
Facility Type:
*
Required
Single Facility (owns/manages 1-4 facilities in Iowa)
Multi (owns/manages 5+ facilities in Iowa)
Does any owner have financial interest in any other health care facilities/agencies in Iowa?
Yes
No
If yes, please list:
Facility Type
For each applicable facility type, please enter the number of beds/apartments.
Are you a CCRC?
Yes
No
Number of Assisted Living Apartments
Number of Home Health / Home Care Agencies
Home Health Certified Agency
Yes
No
If you selected yes to being a Home Health Certified Agency, please identify your 2019 Medicare revenue range. If you are not a Home Health Certified Agency, please select: "Not Applicable".
*
Required
$3 million or higher
$1.5 million to $2.99 million
$750,000 to 1.49 million
$0 to $749,999
Not Applicable
Number of Nursing Facility Beds
Number of Residential Care Facility Beds
Number of Independent Living/Senior Housing Apartments
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Name, Title, Email
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Name, Title, Email
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