2019 Membership Dues Renewal & Assessment
NCHN was formed by members to support their networks. Thank you for your 2019 renewal. It ensures your continued connection to peers across the country, access to the latest news related to health networks, educational opportunities, the latest federal funding opportunities, and other benefits designed to support your work. We look forward to working with you in 2019 and appreciate your continued support.

2019 membership runs from May 1, 2019 - April 30, 2020.

This dues assessment form should be completed by April 1, 2019.

2019 dues must be paid by April 15, 2019.
  • Enter the TOTAL AMOUNT ($) of the network’s most recently reported Operating Expenses, as reported on the network’s 990 form and/or other Internal Revenue Service reporting format, including expenditures for all programs & services, including programs supported by grant funds, and any additional companies that are under the management of the parent organization. NCHN Membership dues are based on your reported operating expenses. Dues are as follows:
    Less than $250,000 = $575
    $250, 001 - $500,000 = $875
    over $500,001 = $1,150

    Renewals are subject to a $35 processing fee. This fee will be shown separately on your invoice.
    Fee inclusive dues totals for 2019-2020 are:
  • If your network does not have a website, please enter "none".
  • Please enter the email address where you would like us to email your dues invoice.

    After we receive your renewal form, we will email an electronic invoice for your dues via PayPal. From that invoice you will be able to pay your dues with a credit card electronically. If you prefer to pay by check, you may do so. If paying by check, please mail it to:, NCHN, 400 S. Main Street, Hardinsburg, KY 40143.
  • NCHN is an organizational membership organization. The network organization is the member of NCHN; however, a contact person for each network must be designated each year to be the official contact for NCHN membership information. Please indicate in the box above, the name of the network’s official representative for 2019. This is the person of record that will receive official NCHN notifications, updates, and other information throughout the year. Please note that the network leader serves as the NCHN official contact for the majority of our members; however, another full-time staff member can be designated the contact by the network leader if desired.
  • Your Network Information

    We constantly strive to maintain up to date information on our member networks. This information is utilized to assist committees in understanding your needs and to assist collaboration among members. We know that your membership composition and programs change periodically. Please take a moment to complete the information below, so we can keep our membership records up to date.
  • Total # of Members
    Ambulance Providers
    Behavioral Health Providers
    Community-Based Organizations
    Community Health Centers
    Critical Access Hospitals (CAH's)
    Free Clinics
    Hospice Agencies
    Hospital-Owned Provider Clinics
    Large Hospitals (>200 beds)
    Long Term Care Facilities
    Medium Hospitals (50-200 beds)
    Oral Health Providers
    Physician Owned Clinics
    Post-Secondary Educational Institutions
    Public Health Departments
    Rural Health Clinics
    Schools/School Districts
    Small Hospitlas (<50 beds)
    Surgical Center
    Other *