2020 Home Health Member Application - Nebraska Health Care Association

Company/Facility Information
Name of Provider*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Director Name*
First Last
Title*
Email*
Phone*
Alternate Representative Name*
First Last
Title*
Email*
Phone*
Initial Contribution*
Price: $500.00
Do you have Branch Offices?*
- Yes
- No
Branch Office Contribution*
Price: $50.00
Number of Branch Locations*
Please enter a number from 1 to 10.

Counties of Service
Please list all of the counties that you provide service in.
Cities of Service
Please list all of the cities that you provide service in.
Services
- OT
- PT
- SLP
- Nursing
- Aide
- DME
- Intravenous Therapy
STAFF MEMBERS
List any staff members below that should have access to the members-only section of nehca.org and be listed to receive NAHAA’s e-newsletter.
Name 1
First Last
Email 1
Title 1
Name 2
First Last
Email 2
Title 2
Name 3
First Last
Email 3
Title 3
Name 4
First Last
Email 4
Title 4
Name 5
First Last
Email 5
Title 5

Payment Information
Credit Cardholder Address
Copy Address information from Facility/Company Address?
- Yes
Address*
Street Address Address Line 2 City State ZIP Code
Cardholder's Email*
Cardholder Name
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

Company/Facility Information