Become a Member

Membership is by individual rural health clinic; and, is specific to clinic location. Interested entities and individuals, other than clinics, are also welcome to become members. Annual membership is for July 1, 2021 - June 30, 2022.

$250 – 1 clinic
$300 – 2 clinics
$350 – 3 clinics
$400 – 4 clinics
$450 – 5+ clinics

pdf Download PDF Application or Apply online now

Rural Health Clinic Name *

CMS Certification Number (CCN) (6 digits) *

TIN *

Address *

City *

State *

Zip *

Website *

Site Contact Name *

Title / Position *

Phone *

Organization *

Country *

Fax *

Email *

Finance Contact Name

Title/Position

Phone

Comment

Annual Fee

1 clinic

2 clinic

3 clinics

4 clinics

5+ clinics

Emails of additional staff to receive newsletter:

If membership is covering additional RHCs, please list clinic name, city, and CCN:

Total Amount

Payment method *

Mail in Payment
Credit Card

Verification code*