2018 Membership Dues Renewal & Assessment
NCHN was formed by members to support their networks. Thank you for your 2018 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 2018 and appreciate your continued support.
2018 membership runs from May 1, 2018 - April 30, 2019.
This dues assessment form should be completed by April 1, 2018.
2018 dues must be paid by April 15, 2018.
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. Dues are as follows:
Less than $250,000 = $575
$250, 001 - $500,000 = $875
over $500,001 = $1,150
Network Leader's Name:
Organization's Website Address:
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.
NCHN is moving to electronic payment for membership dues. A $35 convenience fee will be added to the dues fee amount. Upon receipt of your renewal form, an invoice will be emailed to the above address via Paypal. If you are unable to pay your dues with a credit card, please contact Linda at firstname.lastname@example.org or 217-549-4121
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 2018. 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
Behavioral Health Providers
Community Health Centers
Critical Access Hospitals (CAH's)
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
Small Hospitlas (<50 beds)
*Please specify here, if you entered "other" above.
How can NCHN best support your network needs this year?
Which of the following NCHN benefits are most useful to you? (You may select more than one)
Annual Educational Conference
Everyone’s a Care Giver Subscription
Grant Coaching & Review Services
HCAHPS Webinar Series Subscription
Networking Opportunities with my Peers
NCHN Website - Calendar
NCHN Website - Business Partners Information
NCHN Website - Members Profile
NCHN Website - Membership Map
Quarterly Informational Calls
Special Interest Calls
Tools & Strategies for Managing Networks Website
If you marked "other" please specify here.