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HCAM Membership Application – Additional Facilities

Please use this form to register additional facilities under the same corporation.

HCAM Membership Application - Additional Facilities

Facility Information

Facility Name(Required)

Facility/Community Licensure Number

Facility Address(Required)

Street Address Address Line 2 City State ZIP Code

Name(Required)

First Last

Job Title(Required)

Phone(Required)

Fax

Email(Required)

Website(Required)

Membership Type

Membership Type(Required)

SNF Facility

AL Community

Both SNF and AL

Ownership Type(Required)

Proprietary

Non Profit

County

HLTCU

SNF Number Beds

Number of Licensed Beds(Required)

AL Number of Units

Number of Licensed AFC Units(Required)

Number of Licensed HFA Units(Required)

Number of Other Units(Required)

Total Units(Required)

Accounts Payable Contact

Facility Dues Billing Method

Bill to Facility Directly

Bill to Corporate Office

Name(Required)

First Last

Phone(Required)

Email(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Method(Required)

Email

Mail

Payment Method(Required)

ACH

Check

Corporate / Owner Information

Corporation Name / Independent Owner Name(Required)

Δ

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7413 Westshire Drive | Lansing, MI 48917

Phone: (517) 627-1561 | Email: [email protected]

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