Providers

- Membership Brochure & Reg. Form. (PDF)
- On-line Registration Form

To become a member of Maryland's leading trade organization for long-term health care, fully complete the form below. HFAM offers a 50 percent discount for your first year of membership and a 25 percent discount the second year of membership. Return facility information form to receive pricing and dues information.

On-line Registration Form

I (we) hereby apply for membership in the Health Facilities Association of Maryland and the American Health Care Association. I agree to comply with all the rules and regulations as set forth in the constitution and bylaws of the association and its professional code of ethics, and will make every effort to establish and maintain high standards at all times.

Facility Information:

Facility:
Address:
City, State, Zip:
Phone:
Fax:
E-mail:
Administrator:
County:
License Number:
# of Beds:		Nursing Facility
		Assisted Living
		Other
How long in operation?
How long under present ownership?

Facility Specifics:

Yes No	Is this facility JCAHO Accredited?:
Yes No	Is this facility a member of any other healthcare related Association/Organization?
If yes, please list:
Please check the services you provide to your residents or community:
	Adult Day Care	Recreational Activities
	Alzheimer's Unit	Rehabilitation Services
	Case Management	Respite Care
	Childcare	Retirement Apartments
	Congregate Meals	Senior Center
	Home Health Care	Transportation
	Hospice Care	Ventilator/Special Care Units
	Psychiatric Care	Other:

Owner Information:

Company:
Contact:
Address:
City, State, Zip:
Phone:
Fax:
E-mail:

Is this facility part of a multi-facility corporation?:	Yes No
If yes, identify the facilities in Maryland:

I (we) hereby apply for membership in the Health Facilities Association and the American Health Care Association. I agree to comply with all the rules and regulations as set forth in the Constitution and By-Laws of the Association and its professional Code of Ethics, and will make every effort to establish and maintain high standards at all times.

� 2001 Health Facilities Association of Maryland
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