Membership Application: Skilled Nursing Facility

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"*" indicates required fields

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 – 2025
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

Fax:

Phone:

Email:

Management Company Information

Management Company Name:

Address:

Street Address Address Line 2 City State ZIP Code

Phone:

Fax:

Email:

Referred By: