Application for Membership

Transcription

1 Application for Membership About IPCA The Idaho Primary Care Association is a not-for-profit 501(c)(3) membership organization with a mission to achieve access to affordable, quality healthcare for all through: strengthening and developing community health centers; improving healthcare quality and health outcomes; developing provider workforce; and providing visionary leadership in healthcare policy development. To apply for membership, please include all of the following: Member Category Checklist Organization Information sheet Membership Dues Calculation Form All requested attachments for Membership Category

2 IDAHO PRIMARY CARE ASSOCIATION Application for Membership Member Categories According to the IPCA bylaws, membership is divided into three categories: Organizational; Associate; or Supporting. Organizational Member: Shall be private, non- profit organizations exempt under Section 501- C-3 of the U.S. Internal Revenue Code, or a governmental entity. Meet the organizational and operational requirements for funding under Section 330 of the U.S. Public Health Service Act. The Chief Executive Officer of the eligible organization, or another representative with organizational authority as determined by that organization and approved by the IPCA Board of Directors, shall represent the organization in membership. Associate Member: Shall be private non-profit corporations exempt under Section 501-C-3 of the U.S. Internal Revenue Code, or government entities; AND as judged by a protocol approved by the Board of Directors, which provide comprehensive primary health care services to all members of the community with a specific mission to serve low-income persons and or underserved populations without regard to the ability to pay. The Chief Executive Officer of the eligible organization shall represent the organization in membership. Under special circumstances, an authorized regular representative as determined by that organization and approved by the IPCA Board of Directors, may represent the organization in membership. Supporting Member: Shall be organizations or individuals, judged by a protocol approved by the Board of Directors, that demonstrate a commitment to the corporate mission through programs or activities that support the provision of comprehensive primary health care services to underserved populations. Note: Members wishing to change membership category must complete a new application and must demonstrate that they meet the criteria for the requested category of membership.

3 Member Category Checklist When choosing which category of membership to request, please complete this checklist and send it with your application. Note: you must meet all criteria in a category in order to be eligible for membership in that category. Organizational Member The applicant is a 501(c)(3) not-for-profit organization or governmental entity. The applicant meets the organizational and operational requirements for funding under Section 330 of the U.S. Public Health Service Act. (If unsure, please contact IPCA for more information.) The applicant s board is community based and is composed of at least 51% consumers. The applicant provides comprehensive primary health care*. The applicant provides services without regard to the patient s ability to pay. The applicant provides services to all members of the community. The applicant has a sliding fee schedule. Associate Member The applicant is a 501(c)(3) non-profit organization or governmental entity. The applicant provides comprehensive primary health care*. The applicant has a specific mission to serve low-income persons and or underserved populations. The applicant provides services without regard to the patient s ability to pay. The applicant provides services to all members of the community. The applicant has a sliding fee schedule. Supporting Member The applicant is an individual or organization that demonstrates a commitment to the Association s mission through programs or activities that support the provision of comprehensive primary health care services to underserved populations. * Comprehensive Primary Care is defined as the provision of professional comprehensive health services that includes health education and disease prevention, initial assessment of health problems, treatment of acute and chronic health problems, and the overall management of an individual s or family s health care services. It entails first-contact care of persons with undifferentiated illnesses, comprehensive care that is not disease or organ specific, care that is longitudinal in nature, and care that includes the coordination of other health services.

4 Requested Attachments for Each Membership Category Organizational Member Associate Member Supporting Member A cover letter including a statement explaining the organization s interest in IPCA membership; A copy of the organization s Mission Statement or Statement of Goals; Proof of IRS tax-exempt status; A roster of board members and a description of organization policy ensuring user participation in the development of policy governing primary care service delivery (include name, office held, term, occupation/profession and if board member is a user of the clinic); A description of the comprehensive primary care services offered by the corporation, including hours of operation, types of provider staffing, and provider FTE s; Documentation of revenue sources; Sliding Fee Schedule Most recent notice of grant award or designation under Section 330 of the Public Health Service Act, or other federal grant program A completed Member Application, with requested attachments, Membership Dues Calculation Worksheet. A cover letter including a statement explaining the organization s interest in IPCA membership; A copy of the organization s Mission Statement or Statement of Goals; Proof of IRS tax-exempt status or a statement describing governmental entity status; A description of the comprehensive primary care services offered by the corporation, including hours of operation, types of provider staffing, and provider FTE s; Sliding Fee Schedule; Documentation of revenue sources (documentation of operating budget); A completed Member Application, with requested attachments, Membership Dues Calculation Worksheet. A cover letter including a statement explaining the organization s or individual s interest in IPCA membership and how your organization meets the criteria for membership; A completed Member Application, with requested attachments, Membership Dues Calculation Worksheet.

5 Membership Dues Worksheet Organization: Organizational Member Dues: A. (330 grantees) $1,500 Plus 0.1% of PHS Section 330 Grant Revenue $ Grant Revenue x 0.1% + $1,500 = (dues owed) or B. (FQHC L-A) $1,500 plus.05% of Patient Revenues as reported to HRSA $ Patient Revenue x $1,500 = (dues owed) Associate Member Dues: 0.5% of total operating budget not to exceed $1,500 $_ budget x 0.5% = (dues owed) Supporting Member Dues: (Check one) Individuals: $100 Non-Profit Organizations : $300 For-Profit Organizations: $450 Membership dues are set by the Board of Directors. The membership year is based on fiscal year (October 1-September 30), and first-year dues are pro-rated based on membership effective date: Oct. 1 Dec. 31: Full amount Jan. 1 Mar. 31: Three quarters of full amount Apr. 1 Jun. 30: One half of full amount Jul. 1 Sept. 30: One fourth of full amount Note: once your membership application has been approved, IPCA will invoice you for member dues; you do not need to send with this application.

6 Membership Application Organization Information Sheet Organization Name: _ Administrative Address: _ Telephone: _ Fax: Please indicate who will be your designated representative, and provide contact information for that individual: Name: _ Title/position: _ Address: Phone: _ I certify that all information submitted in this application is, to the best of my knowledge, complete and accurate. Name/Title Date Please send completed application and all forms and attachments to: Idaho Primary Care Association 1087 W. River Street, Suite 160 Boise, ID Please call (208) if you have any questions.

7 Member Benefits & Services Benefits/Services Organizational Associate Supporting Eligibility for election to the Board of Directors All seats available No more than 1 seat No available Eligibility for membership on IPCA committees or workgroups Any Committee Any Workgroup Any Committee* with at least 1 Organizational member present; Any Workgroup Any Committee* with at least 1 Organizational member present; Any Workgroup Voting at general membership meetings 2 Votes per member 1 Vote per member No Federal 330 program application Yes Yes Yes assistance Training Yes Yes Yes Technical Assistance Yes Yes Yes Workforce Development Assistance Yes Yes Yes Notices of funding opportunities Yes Yes Yes Exemption from Idaho State Sales Tax Yes (FQHC s only) No No News & policy updates Yes Yes Yes Legislative services & advocacy Yes Yes Yes Disclaimers: Benefits and Services are subject to IPCA policies & by-laws, and availability of resources. IPCA may charge a fee for technical assistance or training. Advocacy activities are not supported by HRSA. * Excludes IPCA Executive Committee, which comprises Officers of the Board of Directors. IPCA 2013