Join NAHA - National Alliance for Hospice Access

NAHA will maintain, as confidential, the information you provide to us relating to the extent of your Cap problem. We will not disclose specific information pertaining to those facts without your permission. NAHA may summarize data collected to indicate the number of current patients served by NAHA members and the combined extent of the Cap problem for NAHA members. NAHA may also identify member hospices by name in communications with legislators and other decision makers.

Please complete the following form, mandatory fields marked with asterisk.

Your Contact Information * Your Name: Title: * Telephone: Fax: * EMail:

Please complete this section if you represent a hospice. * Hospice Name: Are you an owner? Yes No

* Hospice Address (Main Office / Largest Provider number) Address: Address 2: City: State: Zip:

* Do you have or expect a Cap Problem? 2007 Forecast: Yes No If Yes, amount: 2006 Estimate: Yes No If Yes, amount: 2005: Yes No If Yes, amount: 2004: Yes No If Yes, amount:

* Census / Admissions / Employees at 12/31/2006 Census at 12/31/2006: Medicare Census: 2006 Admissions: Employees at 12/31/06:

Please complete this section if you DO NOT represent a hospice.

* Please briefly describe your interest in Hospice Cap

* Address Address: Address 2: City: State: Zip: