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Skilled Nursing Facility Membership Application

Required information is marked by an asterisk (*)

Incorrectly filled out fields will be highlighted in red

Select the best description for your long-term or residential care community:

Licensed Skilled Nursing Facility: Proprietary Non-Profit

Licensed Boarding Home: Proprietary Non-Profit

Independent Retirement Apartments: Proprietary Non-Profit

Facility Name: *

Address:

City, State Zip:

County:

Phone:

Fax:

Administrator:

E-mail: *

Website:

# of Licensed Beds:

DSHS License #

Owner

Contact Person: *

Contact Person E-mail: *

Address (if different from mailing address):

City, State Zip:

Owner Phone:

Owner Fax:

Applicant Name:

Applicant Title:

Areas of Interest: Please check the areas where you are most interested:

Group Retro

Reimbursement/Rates

Political Action Committee

Quality Improvement

Government Affairs

Education & Training

Convention & Trade Show

Legal Action

Regulations

As an authorized representative of the above named facility, I hereby make application for the facility for status as a Regular Member of the Washington Health Care Association. I hereby certify the above named facility is currently licensed by the State of Washington and has as its principal purpose the provision of residential care services. If accepted for membership, I pledge the facility will support WHCA's Bylaws and such codes of ethics and standards as may be established by the Board of Governors, and will ensure, to the best of it's abilities, provide services consistent with Federal, State and Peer Review Standards. I hereby certify that I am aware of provision 2(c) of Article II of the WHCA Bylaws which states: "If a facility seeks membership, all facilities, portions, units or beds thereof under common control, ownership or operation which are located in the State of Washington must become members."

*You are applying for membership with Washington Health Care Association. By checking this box, you agree to pay membership dues and note that cancellation must be made in writing thirty days prior to cancellation effective date.