WiHPCA Membership Application

WiHPCA Membership Application
The Wisconsin Hospice and Palliative Care Association is committed to ensuring optimal outcomes and growing access to care for individuals facing life-limiting illness by supporting provider members with advocacy, education, strategic partnerships, and community support.
Contact Information
Agency Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact*

First NameLast Name
Title*
Provider Phone Number

Area CodePhone Number
Direct Phone Number*

Area CodePhone Number
Email*
example@example.com
YesNo

Payment Information
Number of Patient Hospice Days*
Dues: $0.12 per patient hospice day, based on 2019 data. Minimum dues is $500. Maximum dues is $8,000.
Minimum Patient Hospice Days
Maximum Patient Hospice Days
Total Amount Due
Invoice Me

Contact Information