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Your GHPCO Benefits! Packet

Includes:
Advocacy
Membership
Benefits
Letter
Information
Membership
Forms
Education Invoice
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Certificate
Care Organization
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950 Eagles Landing Pkwy #622 Now!
Stockbridge, GA 30281
Phone: 404.323.9397
____________________________________________________________________
Georgia’s Expert Resource for Hospice and Palliative Care

It’s Time to Renew Your Membership!

Dear Hospice and Palliative Care Provider:

If you have renewed your program’s membership in the Georgia Hospice & Palliative Care Organization
(“GHPCO”) for the current year please accept our thanks for your continued support! If you haven’t yet renewed your
provider’s membership we encourage you to do so today. Take advantage of our last minute renewal offer - when
you join GHPCO prior to December 1, 2018 you may redeem the enclosed workshop gift certificate good for one
attendee registration at any 2018 GHPCO Workshop!

If your hospice or palliative care program is not currently a GHPCO member we ask that you consider the
benefits of membership. Below is a brief outline of key benefits we feel are important to hospice providers. As a
member-supported organization, this is your GHPCO and we welcome your suggestions on how we may better serve
the interests of the hospice in Georgia. The support of ALL hospice and palliative care providers in Georgia puts the
GHPCO on its best footing to serve you and the interests of hospice.

ADVOCACY
 Expert advocacy and communication with the Department of Community Health’s Medicaid division
 Legislative Support and Representation at the State Capitol
 Advocacy at Medical Care Advisory Committee to Department of Community Health
 Advocacy and Collaboration with DCH’s Healthcare Facilities Regulation Division
 Representation at the Palmetto Hospice Coalition

INFORMATION
 Members-only listing in online searchable database for consumer and referral-source use as well as patient
referrals via our Referral Helpline
 Representation at State and National Events
 Access to Market-specific utilization and demographic data reports and trend analyses
 Regional Meetings and Networking Opportunities
 GHPCO Members Newsletter /Hospice News Network information/ Updates and Alerts with breaking information
 Technical assistance from subject matter experts in GHPCO

EDUCATION
 Substantial discounts at GHPCO Education Events and Conferences
 Members-only discounts for products and services to optimize operations
 Access to Education outside of GHPCO for optimal use of education dollars

Membership dues from programs like yours is our largest source of funding, funding that allows the GHPCO to
continue its vital work on your behalf in important areas such as advocacy, access and quality. But we need your help
to make this possible and we ask that you will put joining GHPCO at the top of your priority list. For your convenience
we have included a Provider Membership Application and invoice. Should you have any questions about the form, your
membership, or if you would like to learn more about what you can do to partner with us, please let us know. We look
forward to your participation in GHPCO throughout the year!

In partnership,

Paula Sarah

Paula Sanders Sarah Thompson, RN. CHPN

Executive Director Chair – Membership Committee

950 Eagle’s Landing Pkwy #622 Stockbridge, GA 30281 www.ghpco.org ph: 404-323-9397 fax: 678-623-0175
____________________________________________________________________
Georgia’s Expert Resource for Hospice and Palliative Care
NOTE: If you are a hospice with multiple locations and are submitting your membership renewal for all locations at
once, please complete a copy of this page for EACH additional location and return with your application.

Provider Membership RENEWAL Application

(Membership year runs April 1, 2018 – March 31, 2019)

Section I: Contact Information.

Name of Organization: ________________________________________________________________________

Address: ______________________________ _________ ____________________ ______ ___________
(Street) (PO Box) (City) (State) (Zip Code)
Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Fax: ( _ _ _ ) _ _ _ - _ _ _ _ Website: _____________________________________
Primary Contact Name: ______________________________Title: ____________________ Email: _____________
(Primary Contact person will receive all mailings, etc. from GHPCO and will be listed as the primary contact on the GHPCO website as well as serve as
the Voting Delegate at the Annual Conference)

Additional Email Contacts for Information (education, clinical, regulatory, etc):

Name: ________________________________________ E-mail: ____________________________________________
Name: ________________________________________ E-mail: ____________________________________________
Name: ________________________________________ E-mail: ____________________________________________

Section II: Changes to Organization Information:

Please document any changes to information submitted previously for accurate reflection in the online database and member records.

Counties served: ________________________________________________________________________________________________________________________

Does your organization operate a Hospice In-Patient and/or Residential Facility? Yes No
If yes, please provide the following:
Hospice Facility/Unit Name: ______________________________________________________________________
Address: ___________________________ _______________ ____________________ _________ ___________
(Street) (PO Box) (City) (State) (Zip Code)
Phone: ( _ _ _ ) _ _ _ - _ _ _ _ Fax: ( _ _ _ ) _ _ _ - _ _ _ _ Website: _________________________________
Primary Contact: __________________________ Title: ________________ Email: _________________________
What is the total number of beds in the facility/unit named above? ___________

Accredited by: Not accredited JCAHO CHAP ACHC Other (please specify):
______________
Member of NHPCO?: Yes No
Member of NAHC?: Yes No
Separate non-hospice Palliative Care Program? Yes No
Pediatric Hospice/Palliative Care Program? Yes No
950 Eagle’s Landing Pkwy #622 Stockbridge, GA 30281 www.ghpco.org ph: 404-323-9397 fax: 678-623-0175
____________________________________________________________________
Georgia’s Expert Resource for Hospice and Palliative Care

Section III- Membership Fees

A. Hospice Providers
The Georgia Hospice and Palliative Care Organization charges dues based upon a minimum annual fee of $250.00 (Basic level) plus $3.50 per new
patient admitted in the previous calendar year, up to a maximum of $10,000.00.

Calculate dues based on patient admits for previous calendar year plus membership level

A Provider Membership Minimum Fee (BASIC LEVEL) $250.00

B Total Number of new Patients admitted in previous calendar year
C Per Patient Fee = $3.50 $3.50
D Patient Sub-total = (C x B)
TOTAL

E EARLY DUES DISCOUNT – 2% DISCOUNT FOR DUES PAID PRIOR TO April 1, 2018!

Corporate Flat Rate – organizations with 7 or more locations licensed in the state of $10,000
F
Georgia
$250.00
G Palliative Care Provider Member FLAT RATE

TOTAL DUES CALCULATED

Total number of locations covered by this Application: ___________________

B. Palliative Care Program Providers

The Georgia Hospice and Palliative Care Organization charges palliative care program dues of $ 250 per year (no prorated dues are offered).
Palliative Care providers receive basic membership benefits.

C. Anthony Leatherwood Leadership Legacy Scholarship donation: ____________________

Scholarship supports attendance for a rising hospice leader at the GHPCO annual conference and the NHPCO Management Development
Program in Washington DC in honor of Anthony Leatherwood, former GHPCO board president and tireless hospice leader.

Total Dues Payment Submitted for this membership year: ______________________________________________________

Everything stated in this form is correct and complete to the best of my knowledge.

Person completing this form: ____________________________________________________________

(Signature) (Title)

Please Print Your Name: Date: _____ / _____ / _____

( mm) ( d d ) (y y)

NOTE: Only Provider members in good standing (i.e. existing, current members who have paid their dues in full) shall be eligible to nominate
and vote at the Annual Conference to elect directors to the GHPCO Board. Only representatives from Provider members in good standing shall
be elected to serve on the Board of Directors of GHPCO.

Questions: Please, feel free to contact the GHPCO office at toll-free 877-924-6073 or email us: admin@ghpco.org

950 Eagle’s Landing Pkwy #622 Stockbridge, GA 30281 www.ghpco.org ph: 404-323-9397 fax: 678-623-0175
____________________________________________________________________
Georgia’s Expert Resource for Hospice and Palliative Care

PAYMENT
Please send the:

1. Completed Provider Membership RENEWAL form

2. A copy of your organization’s State of Georgia License (from DCH – not business license)
3. This Payment form... and
4. Payment
TO: Georgia Hospice and Palliative Care Organization
950 Eagles Landing Parkway
Suite #622
Stockbridge, GA 30281
Or via fax to 678-623-0175

Payment may be made by check or credit card as indicated. Credit cards are processed via PayPal and may reflect on
statements as “PayPal” as well. Please make check(s) payable to “GHPCO”.

Check ___________ Check No. _________________ Date: ________________ Amount: ____________________________________

MasterCard _______________ Visa __________________ American Express _______

CARD No.:____________________________________________________________________ Expiration Date: /

(mm) (yy)
CVV (3 digits on back or 4 digits on front if AMEX) _____________

Billing Address: ____________________________________________________________ zip _____________

Cardholder’s Name (Please Print):_________________________________________________________________

950 Eagle’s Landing Pkwy #622 Stockbridge, GA 30281 www.ghpco.org ph: 404-323-9397 fax: 678-623-0175
____________________________________________________________________
Georgia’s Expert Resource for Hospice and Palliative Care

Georgia Hospice and INVOICE # 001

Palliative Care Organization DATE: JULY 23, 2018

950 Eagles Landing Parkway Suite 622

Stockbridge, GA 30281
Phone 404-323-9397 Fax 678-623-0175
admin@ghpco.org

TO GHPCO Provider Member

Join or Renew Your Membership Dues Now!

SHIPPING PAYMENT
SALESPERSON JOB METHOD SHIPPING TERMS DELIVERY DATE TERMS DUE DATE

Paula Sanders Membership N/A Due on receipt 04/01/2018

QTY ITEM # DESCRIPTION UNIT PRICE DISCOUNT LINE TOTAL

Basic Dues Base Hospice Provider Rate $250

Basic Dues Palliative Care Provider Rate $250

Hospice Membership dues renewal for 2018-2019

Provider membership year $3.50/admission
DUES $3.50 per admission
EARLY DUES DISCOUNT – 2% FOR DUES PAID
DISCOUNT
PRIOR TO April 1, 2018

TOTAL DISCOUNT

SUBTOTAL

SALES TAX -

TOTAL

Submit attached Membership Renewal form with dues calculation to admin@ghpco.org or fax to 678-623-0175

Make all checks payable to Georgia Hospice and Palliative Care

THANK YOU FOR YOUR BUSINESS!

950 Eagle’s Landing Pkwy #622 Stockbridge, GA 30281 www.ghpco.org ph: 404-323-9397 fax: 678-623-0175
Redeem Certificate For Free Registration To
Any GHPCO Sponsored Workshop.
Valid from June 1, 2018-December 31,2018
Name:

Date:
_____________

Paula Sanders
Paula Sanders, GHPCO Executive Director