CFC Membership Application Form

CashForCare Membership Application

To apply for membership please complete all the questions. One application and fee are required per business. Additional employees/providers can join and set up profiles after the main applicants' approval. For questions contact info@cashforcare.com or call 719-888-3225
Applicant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Company Name*
Website*
Applicants Email*
example@example.com
Applicants Phone Number *
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary Industry/Speciality: (Primary Care, Physical Therapy, Behavioral Health etc)*
List your core services offered by your practice/business.
Length of time in Industry/Speciality:*
Is the Industry/Speciality under which you are applying for membership your primary occupation?*
Industry Experience: Please detail your experience in your industry/speciality: (i.e. trigger point therapy, women's health, cupping, dry needling, etc.)*
Education Background: List specific degrees, current license, credentials required to perform in industry/speciality. Please list address and location of schools, universities, training programs if applicable.*
Has your professional license ever been revoked or suspended? If yes, please provide details:*
Have you been convicted of a felony?*
How did you hear about CashForCare?
Professional References

NOTE: It is the applicant's responsibility to get permission from the client or patient to use them as a reference. Please follow applicable HIPAA laws when providing this information. We will not ask about the medical history or the treatment plan. Sample questions will be: Did they practice ethically, pricing, delivery of services, etc. If unable to provide a client or patient reference please provide an additional business reference.
Professional Reference #1
Name*

First NameLast Name
Relationship (Business/Client/Patient):
If business, name of business:
If business relationship, position/title:
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Professional Reference #2
Name*

First NameLast Name
Relationship (Business/Client/Patient):
If business, name of business:
If business relationship, position/title:
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
MEMBERSHIP TERMS AND CONDITIONS

By submitting this application, you agree to the CashForCare membership code of ethics, terms, policies, and guidelines. Click the blue hyperlink below to review the terms and conditions.
CODE OF ETHICS

Upon acceptance to CashForCare, I agree to abide by the following Code of Ethics during the membership term.

1. Provide transparent pricing for my services on the CashForCare directory.

2. Provide quality services at the price that I have quoted.

3. Conduct services professionally with honesty and integrity while accurately representing my profession and organization.

4. Avoid offering services that are known to be unnecessary or non-effective, nor will I provide false or misleading information or engage in any activity or scheme intended to defraud members, clients, or referral partners/organizations in the CFC network.

5. Treat all clients with dignity, respect and courtesy and will use my professional judgment when assessing them.

6. Execute goodwill, benevolence, and trust among patients, providers and referrals.

7. Take responsibility for contacting the inquiries and requests for service received in a timely manner and maintain clear communication with clients and referral partners in the CFC network.

8. Uphold the ethical standards and HIPAA protocols of my profession.

9. Maintain the state and federal standards and required licensures and certifications within my profession.

10. Take responsibility to update price changes and/or information regarding my organization on the CareForCare directory and will honor pricing and/or statements previously listed, if not updated.

Professional standards outlined in a formal code of conduct for any profession supersede the above standards.
APPLICATION AND MEMBERSHIP DUES

Prospective members must complete the membership application and submit the non-refundable $50 application fee to the CashForCare Membership Committee to begin the membership process. Applications will not be considered or reviewed otherwise. Upon completion of the interview and vetting process, the remaining monthly/annual dues are required to be paid before the applicant’s profile will be featured in the CFC directory. The Membership committee reviews applications on a monthly basis and will notify you of acceptance or denial by phone and/or email.

Dues are as follows:

$50 Initial Application Fee (Due Today)

$19.95 month-to-month (Due After Acceptance)

OR $199.95 annually (Due After Acceptance)
Signature*

Clear
Signature Date*

MonthDayYear
Date

Payment*

Membership Application Fee

$50.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

CashForCare Membership Application

Professional References

Professional Reference #1

Professional Reference #2