EmailMeForm
2022 Membership Renewal & Dues Assessment
NCHN was formed by members to support their networks. Thank you for your 2022 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 you and your network. We look forward to working with you in 2022 and appreciate your continued support.
2022 membership runs from May 1, 2022 - April 30, 2023.
This dues assessment form should be completed by April 1, 2022.
2022 dues are expected to be paid by April 15, 2022.
Network/Organization Name:
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Most recent fiscal year operating expenses (the total operating expenses reported on your 990 or other tax form):
*
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.
Less than $250,000 = $650
$250, 001 - $500,000 = $950
$500,001 - $750,000 = $1,250
$750,001 - $1,000,000 = $1,550
$1,000,001 - $5,000,000 = $1,850
over $5,000,000 = $2,150
Network Leader's Name:
*
Job Title:
Email
*
Mailing Address:
City:
State:
Zip Code:
Organization's Website Address:
*
If your network does not have a website, please enter "none".
Payment
*
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
c/o Linda Weiss
231 NW 53rd Street
Oakland Park, FL 33309
Official Contact
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 2022. 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.
Official Contact Email Address
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.
Network Programs and Services
Member Composition (please enter the # of each member type)
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 *
*Please specify here, if you entered "other" above.
Which of the following NCHN benefits are most useful to you? (You may select more than one)
Annual Educational Conference
Conversation Connections Calls
Discount on Augmedix Scribing Services
Discount on BoardEffect board management platform
Discount on GrantStation Subscription
Discount on Saybrook University MBA or DBA program
Educational Bites
eNews
Grant Coaching & Review Services
Hospital Network Leader Roundtable
Leadership Experience
List Serve Queries
Networking Opportunities with my Peers
NCHN Website - Calendar
NCHN Website - Members Profile
NCHN Website - Membership Map
Quarterly Informational Calls
Special Interest Calls
Tools & Strategies for Managing Networks Website
Training Webinars
Other - please specify
Are there any services not being offered that you are interested in receiving from your professional association?
Do you currently receive grant funding?
Yes
No
If yes, please indicate which program(s) you receive grant funding
HRSA Rural Health Network Development Planning
HRSA Rural Health Network Development
HRSA Rural Communities Opioid Response Program-Implementation
HRSA Rural Communities Opioid Response Program-Psychostimulant Support
HRSA Rural Communities Opioid Response Program – Behavioral Health Care Support
HRSA Rural Communities Opioid Response Program – Neonatal Abstinence Syndrome
HRSA Rural Public Health Workforce Training Network Program
HRSA Small Health Care Provider Quality Improvement Program
HRSA Delta Region Rural Health Workforce Training Program
HRSA Rural Health Care Services Outreach Program
HRSA Rural Health Care Coordination Program
HRSA Small Health Care Provider Quality Improvement Program
HRSA Telehealth Network Grant Program
SAMHSA Harm Reduction Grant Program
USDA ReConnect Program
Foundation Grant
State Grant
Local Grant
Other - please specify
How can NCHN best support your network needs this year?