SCHCHA 25/26 MEMBERSHIP APPLICATION

STEP 2 OF 4 | Membership Dues Calculation
Dues are based upon a parent entity’s gross revenue for the most recent fiscal year from all offices in South Carolina. For the purpose of dues calculation, gross revenue includes revenue from Certified Medicare / Medicaid Home Health services such as intermittent home care visits (nursing, aide, PT, OT, SLP, MSW, nutrition, and supplies); Hospice services, Medicaid Waiver Personal Care Services and Private Duty Home Care. Revenue is regardless of payor source and includes Medicare, Medicaid, insurance and private pay.

(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.)
A. Revenue received from Medicare / Medicaid Certified Home Health:
B. Revenue received from Hospice Services:
C. Revenue received from Medicaid Waiver Personal Care Services:
D. Revenue received from Private Duty Home Care:
Total Revenue for Dues Calculation:
Using the total from Sections A-D, calculate your annual dues using the following scale.
For The Person Authorized To Verify Gross Revenue:
Name:
Title:
Telephone
Include area code.Format: (000) 000-0000.
Signature

STEP 3 OF 4 | Payment
All membership dues must be paid in full. Dues may be paid by check, ACH, or credit card. Make checks payable to: South Carolina Home Care & Hospice Association (SCHCHA), 1511 Sunday Drive, Suite 318, Raleigh, NC 27607.
Enclosed is a check in the amount of
Pay by ACH in the amount of
SouthernFirst Bank, Routing #053208011, Acct # 1649524
If paying by ACH please email this completed application to judy@ahhcnc.org.
VISAMasterCardDiscoverAmerican Express
Account No.
Expiration Date

MonthDayYear
Date
Sec. Code
Name on Card
Address of Cardholder
City
State
Zip
Signature:
(as it appears on credit card)

IMPORTANT NOTICE: All reported membership information is confidential. Dues payments to the SC Home Care & Hospice Association are not deductible as a charitable contribution for federal income tax purposes. However, dues payments may be deductible as ordinary and necessary business expense, subject to exclusion for lobbying activity. Because a portion of your dues is used for lobbying by the SCHCHA, 30% of your dues are not deductible for income tax purposes.

If you have any questions about dues payments, please call the SCHCHA office at 919-848- 3450 or e-mail Judy Penn, COO, judy@ahhcnc.org. Please complete this renewal form and return with dues payment to the SCHCHA, c/o AHHC, 1511 Sunday Drive, Suite 318, Raleigh, NC, 27607.

STEP 4 OF 4 | Additional Office Membership
(Make copies of this form to list additional offices, if necessary)

Please Complete This Form If You Have More Than One Office Located in South Carolina. This Will Ensure That Each Office Receives All Member Benefits.
Agency Name
Administrator
E-Mail Address
example@example.com
Mailing Address
City
State
Zip
Telephone
Format: (000) 000-0000.
Additional Staff E-Mails for this location:
Name
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Agency Name
Administrator
E-Mail Address
example@example.com
Mailing Address
City
State
Zip
Telephone
Format: (000) 000-0000.
Additional Staff E-Mails for this location:
Name
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Agency Name
Administrator
E-Mail Address
example@example.com
Mailing Address
City
State
Zip
Telephone
Format: (000) 000-0000.
Additional Staff E-Mails for this location:
Name
example@example.com
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Name
E-Mail Address
example@example.com
Should be Empty:

SCHCHA MEMBERSHIP ONLINE APPLICATION