MEMBERSHIP Application
Company Information
Company Name
Main Location Address
City/State/Zip ,
Phone #
Web Site Address
Fax #
Primary Contact
Email Address
Alternate Contact
Email Address
Year Company Founded
Years in HME Business

Branch Locations
Branch #1
Address
Phone #
City/State/Zip ,
Fax #
Branch #2
Address
Phone #
City/State/Zip ,
Fax #

Ownership Structure
Our company is: Independently Owned
Hospital Affiliated
Publicly Held
Subsidiary of Parent Corporation

Scope of Service
Traditional Home Medical Equipment% of Total Service:
Respiratory Services% of Total Service:
Rehab & Assistive Technology% of Total Service:
Supplies% of Total Service:
Pharmaceutical Services/Infusion% of Total Service:
Other% of Total Service:
Annual Gross Volume in Revenue
:

Staffing
Number of Full Time Employees
:
Does your company employ the following:
Respiratory Therapists# Nurses#
OT/PT# Rehab Techs#
Pharm D's# Other#

Industry Involvement
Are you or any of your staff involved in the following organizations?
American Association for Home Care (AAH)
State Association
RESNA
NRRTS
AARC
NAIT
Other organizational affiliation and/or consumer advocacy groups?
Are you a member of any Buying Groups? Yes No
If yes, please list:

Accreditation
Select any accreditation status:
JCAHO CHAP ACHC ISO Other (list below) None

Comments:

Most Important Issues That Affect Your Financial Performance
Reimbursement
Supply Costs
Cash Management
Business Financing		 Benchmarking
Accreditation
Debt Restructure
Leasing		 Business Metrics
Staffing
Operations
Managed Care		 Business Modeling
Regulatory
Competitive Bidding
Employee Management		 Networking
Education/CEUs
Repairs

Supplier Volume
List in descending order your five largest suppliers:Estimated Annual Volume
1. $
2. $
3. $
4. $
5. $

MED Referral
How did you hear about MED? What interests you about MED Membership?


Click the Submit button below to submit electronically, or click here to open a printable version of this form that can be filled out and faxed to:


806-792-4499, Attn: Dan Smith

By clicking on the submit button of the electronic membership inquiry, "Applicant" authorizes The MED Group to obtain and use background information and consumer credit reports that may be necessary to evaluate this application. This process and the information utilized could result in the denial of the application. "Applicant" also expressly authorizes The MED Group to contact any third parties, including appropriate suppliers, to obtain information about "Applicant's" accounts and payment histories. "Applicant" waives any right or claim that might be otherwise held under the Fair Credit Reporting Act. "Applicant" releases and indemnifies The MED Group from any liability resulting from acquiring and using such information.


Please click the Submit button below to send your membership inquiry to The MED Group. Once you click the Submit button, the information will be transmitted and you will be able to close this window.