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Skilled Nursing Facility Membership Application

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:

E-mail:

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."

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