THCA SNF Membership Application
Application for Skilled Nursing Facilities
Name of Person Completing Form
*
First Name
Last Name
Title
*
Organization
*
Email
*
Confirmation Email
example@example.com
Facility Name
*
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from Facility Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Administrator Name
*
First Name
Last Name
Facility Administrator Company E-Mail Address
*
Confirmation Email
example@example.com
Facility Owner Name
*
Facility Owner Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility Managed by:
*
Management Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Management Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facility Classification
*
Hospital-based/owned
Privately owned/operated
Government owned/operated
Multi-facility owned/operated
Non-profit
For profit/proprietary
Does your facility provide any home and community based services?
*
Yes
No
If yes, please check all that apply:
Adult Day Care
Personal Care Services
Homemaker Services
Assistive Technology
Case Management
Home-delivered Meals
In-home Respite Care
Inpatient Respite Care
Minor Home Modifications
Personal Care Assistant
Personal Emergency Response System
Pest Control
Other
Please complete and fill all windows. If not applicable, enter "0".
Total Number of Licensed Beds
*
Number of Medicare Beds
*
Number of Medicaid Beds
*
Please select each of the services that your facility/community provides:
Alzheimer's Unit
Bariatric Services
Behavioral Unit
Child Care Center
Ventilator
Outpatient Therapy
VA Services
Non-elderly Disabled Services
Greenhouse/Cottages
Independent Living
Hospice Care
Memory Care
Other
I hereby apply for active membership in the Tennessee Health Care Association. I understand that this application will be reviewed and must be approved by the THCA Board of Directors. If this application is accepted, I agree to abide by the association’s bylaws. I also am aware that at least one-fourth of total annual membership dues must be paid before benefits are available.
*
Yes
Signature
*
Continue
Continue
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