Membership Form

Indicate Membership Categories

Provider Member

Provider Members shall be any organization licensed by their state or certified by Medicare to provide hospice care. Membership is based on Medicare Provider #. Each provider number must be separate membership. Full voting rights.

Number of patients served (per 2013 per DHSS Hospice Statistical Report):

NOTE annual minimum dues $420 and annual maximum dues $5,500

Palliative Care Membership

Shall be a provider of Palliative Care that is not a hospice program provider. Full Voting Member.

Annual Dues $450

Associate Member

Associate Member shall be any association or institution which is not eligible for membership as a Provider Member but which supports the purpose of MHPCA (This could be any organization which is developing a hospice program or an association or a vendor.) Non-voting member.

Annual Dues $400

Individual Member - Hospice or Palliative Care Affiliated

Annual Dues $150

Individual Member - Non Hospice or Palliative Care Affiliated

Annual Dues $100


Donation to MPHCA: $


All Fields Required

Organization / Individual
Administrative ContactTitle
Email Address
Street Address
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ALL fields in RED are REQUIRED!