• AHHC ONLINE MEMBERSHIP APPLICATION

    AHHC ONLINE MEMBERSHIP APPLICATION

    2026/2027

  • Instructions

    This is the new online membership form. You can save this document and return to complete it later by clicking save at the end of each page. Please be sure to fill out your email on the first page. You must complete the required fields on the page prior to saving. When you save, you will receive an email with a link to return to finish the form, or you can copy the link from the pop-up to get a draft link. After you complete it, you can print a copy of your application. Be sure to click SUBMIT before leaving the application.

  • Step 1 of 5 | Info

  • Ownership:*
  • Is your Home Care Agency Medicare-Certified?*
  • Do you provide Hospice Services?*
  • Do you operate a Hospice Residential Facility?*
  • Is your Agency accredited?*
  • Is your Agency a provider of Medicaid PCS services?*
  • Is your Agency a provider of Medicaid CAP services?*
  • Is your Agency a provider of Medicaid PDN services?*
  • Is your Agency a provider of Behavioral Health services?*
  • Is your Agency a provider of Companion/Sitter services?*
  • Is your Agency a member of the National Alliance for Care at Home?*
  • Is your Agency a member of HCAOA?*
  • Is your Agency a member of NPHI (National Partnership for Healthcare and Hospice Innovation)?*

  • Names & Email Addresses of Key Staff for the Above Office ONLY:

    For additional emails for this office, please attach a list with names and emails of all employees that should be on the listserv to receive AHHC's emails, see page 6 to include emails for additional offices/locations

  • Step 2 of 5 | Number of Licensed Offices

  • If your parent entity has more than one office operating in North Carolina, other than the office listed in STEP 1, be sure to complete the form below entitled, "Additional Office Membership". The number of offices you indicate on the form, should match the number of licensed sites on record at the Division of Health Services Regulation.

  • Step 3 of 5 | Membership Dues Calculation:

    Dues are based upon a parent entity's gross revenue as defined below.

  • Definition of Gross Revenue

    Definition of Gross Revenue Gross revenue is defined as: the parent entity's revenue for the most recent fiscal year, from all offices in North Carolina, which provide in-home and community-based services of any kind. All agencies that are related by common ownership or control shall be treated as a single member for that purpose. Revenue is regardless of payor source. The following services in Section A-G must be included when calculating gross revenue. Please indicate gross revenue for each service category and total where indicated. (When calculating gross revenue, you may exclude the following items: contractual adjustments, bad debts; investment income, charitable donations, funds raised through special events and philanthropic dollars As always, this information will be kept strictly confidential.

    ***Note*** It is imperative that you answer each revenue section as accurately as possible. If a question does arise, additional information and verification may be necessary.

  • A. Home Health & Home Care Services

    This includes, but is not limited to, revenue from: Nursing, Aide, PT, SLP, OT, MSW, nutrition, sitter, companion, homemaker, respite, home medical equipment (HME/DME), and supplies. Revenue is regardless of payor source, including Medicare, Medicaid, insurance, alternative or bundled payment models, PACE, Division of Aging & Adult Services and private pay. Also include PCS, PDN, CAP/DA & CAP/C services (CAP-I/DD revenue should be reported in section G).

  • B. Hospice & Palliative Care Services

    This includes freestanding hospice in-patient and residential facility revenue, hospice routine home care services and Palliative Care, regardless of place of service. (Do not include in gross revenue any general in-patient care provided through contract by a hospital or nursing home. Also, do not include nursing home room and board charges for hospice nursing home patients.)

  • C. Case Management Services

    This includes, but is not limited to: CAP case management, HIV case management and private case management services.

  • D. Supplemental Staffing Services

    This includes revenue generated from providing staffing to other home care agencies and assisted living facilities (including adult care homes and multi-unit assisted housing with services Do not include revenues generated from staffing ICF's, SNF's and hospitals.

  • E. Infusion Services

    This includes revenue generated from, but not limited to: pharmaceuticals, infusion equipment, and Medicaid HIT

  • F. Adult Day Health, Day Care and Transportation Services

  • G. Mental Health Services

    This primarily includes behavior health or IDD services including CAP-I/DD, and any mental health servies that require a home care license for the provision of that service.

  • Using the total from Sections A-G, calculate your annual dues using the following scale

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  • Step 4 of 5 | Verification of Revenue

    For the person authorized to verify Gross Revenue:
  • Format: (000) 000-0000.

  • Step 5 of 5 | Payment

  • All membership dues must be paid in full to avoid a 5% surcharge. Dues may be paid by check, ACH,or credit card. Make checks payable to: Association for Home & Hospice Care of NC (AHHC), 1511 Sunday Drive, Suite 318, Raleigh, NC 27607.

  • Southern First Bank, Routing #053208011, Acct # 1649524.
    If paying by ACH please email this completed application to judy@ahhcnc.org.

  • Paying by Credit Card

  • Please note a 3% surcharge will be applied to all credit card payments to offset banking fees.

  • Paying by Credit Card?

    Please contact Kerri Ogburn at 919-848-3450 x100 to process your payment.

  • ADDITIONAL OFFICE MEMBERSHIP FORM

  • (Make copies of this form to list additional offices, if necessary)
    Please Complete This Form If You Have More Than One Office Located in North Carolina. This Will Ensure That Each Office Receives All Member Benefits.

  • Format: (000) 000-0000.

  • Is this licensed site Medicare-Certified?

    Does this site provide Medicaid PCS Services?

    Additional Staff E-Mails for this location:

  • Is this licensed site Medicare-Certified?
  • Does this site provide Medicaid PCS Services?

  • Additional Staff emails for this location:

  • Format: (000) 000-0000.
  • Is this licensed site Medicare-Certified?
  • Does this site provide Medicaid PCS Services?

  • Additional Staff emails for this location:

  • Format: (000) 000-0000.
  • Is this licensed site Medicare-Certified?
  • Does this site provide Medicaid PCS Services?

  • Additional Staff emails for this location:

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  • Should be Empty: