Become a Member

Annual membership is for July 1, 2022 - June 30, 2023

$250 - Allied Organization/Individual Membership
$250 – 1 clinic
$300 – 2 clinics
$350 – 3 clinics
$400 – 4 clinics
$450 – 5+ clinics

Please Note: If you plan to submit membership for multiple clinics, the intent of the dues structure is to include only the clinics under the same clinic administrator. This structure is not meant to include all clinics within a regional structure. See the following scenario.

Region X includes 10 clinics within its health system. One clinic administrator is responsible for 3 clinics within that region. Therefore, the membership dues in this instance would be $350 for the 3-clinic rate. In this scenario, Region X is not eligible for membership at the 5+ clinic rate to include all 10 clinics.

If you have questions regarding membership or payment processing, please contact Hannah Toresdahl at

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

Email *

Comment

Annual Fee *

1 clinic

2 clinic

3 clinics

4 clinics

5+ clinics

Allied Organization/Individual Membership

Emails of additional staff to receive newsletter:

If membership is covering additional RHCs, please list clinic name, city, and CCN. If not registering additional RHCs, please put NA. *

Total Amount

Payment method *

Credit Card
Mail in Payment

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*