Provider Membership - Alabama Hospice and Palliative Care Organization

Comments

This field is for validation purposes and should be left unchanged.

Corporate / Parent Office Information

Please complete whether you are responding from corporate office or branch office. Branch contacts collected in Part 2.

Company / Parent / Agency Name(Required)

CEO / Preferred Contact — First Name(Required)

CEO / Preferred Contact — Last Name(Required)

Email Address(Required)

Physical Address(Required)

Physical City / State / ZIP(Required)

Mailing Address (if different from physical)

Mailing City / State / ZIP

Telephone(Required)

Fax

Website

Section Two — Dues Calculation

Per AHPCO bylaws: base $1,000 + $5 per unduplicated admission (capped at $7,500 line) + $50 if Palliative Line included. 2% early-payment discount applied automatically if paid before Feb 1, 2026.

Number of Unduplicated Admissions(Required)

Please enter a number greater than or equal to 0.

Use the unduplicated admissions number from your most recently submitted SHPDA Data Collection Tool (Line B1a).

Include your Palliative Care Line of Business as a member of AHPCO? (+$50)

Yes

No

Palliative Care Line of Business Name

Membership

Price: $0.00

Base $1,000 + $5 per admission (capped at $7,500) + $50 if palliative line included. 2% early-payment discount handled automatically at checkout.

Agreement & Payment

By submitting this form you agree to the AHPCO Ethics, Antitrust Compliance, and Collection of Information Statements (full text available on the AHPCO website).

I have read and agree to AHPCO's Ethics, Antitrust Compliance, and Collection of Information Statements.(Required)

I have read and agree

Communication Preferences

I prefer NOT to receive occasional AHPCO communications

Do NOT include my contact information in vendor lists

Credit Card(Required)

Become an AHPCO Provider Member

Corporate / Parent Office Information

Section Two — Dues Calculation

Agreement & Payment