Membership Application: Skilled Nursing Facility

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Facility Information:
Facility Name:*
Administrator:*
Address:*
Street Address Address Line 2 City State ZIP Code
Phone:*
Fax:
Email:*
Type of Facility:*
- Proprietary
- Non-Proprietary
Annual Membership Dues Rates – 2024
Arizona Health Care Association (AHCA): $58.21 per licensed bed
American Health Care Association (AHCA): $21.63 per licensed bed
Annual Total: $79.84 per licensed bed
State License(s) & Type Number(s):*
Total # of Beds /Units - SNF:
Total # of Beds /Units - AL:
Total # of Beds /Units - Independent:
Your Name:*
Your Email:*
Owner Information:
Owners Name:
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Fax:
Email:
Management Company Information
Management Company Name:
Address:
Street Address Address Line 2 City State ZIP Code
Phone:
Fax:
Email:
Referred By: