Network Member Application
After submission, your application will be sent to the NCHN Board of Directors for approval and you will receive an email regarding your application status shortly. Membership dues are billed annually. You will be invoiced the prorated amount for this year.
  • Network Information

    Enter information about your network below.
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  • NCHN annual dues are determined by the member organization’s most recent fiscal year’s operating expenses, as reported on their 990 form and/or other Internal Revenue Service reporting format, including expenditures for all programs and services, including programs supported by grant funds, and any additional companies that are under the management of the parent organization.
  • Number of Members
    Ambulance Providers
    Behavioral Health Providers
    Community-Based Organizations
    Community Health Centers
    CAH's
    Free Clinics
    Hospice Agencies
    Hospital-Owned Provider Clinics
    Large Hospitals (>200 beds)
    Long-Term Care Facilities
    Medium Hospitals (51-200 beds)
    Oral Health Providers
    Physician Owned Clinics
    Post-Secondary Educational Institutions
    Public Health Departments
    Rural Health Clinics
    Schools/School Districts
    Small Hospitals (26-50 beds)
    Surgical Center
    Other
  • Enter types of members that are included in "Other" (e.g., Home Health, EMS Providers, etc.)
  • Director Information

    Enter information for your network director or the primary contact for NCHN
  • Additional Staff

    Would you like to have other staff members receive the NCHN e-News (distributed on the first and third Tuesday of every month)? If so, please add these below:
  • Name (First & Last) Title Email Address
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