Member - Kentucky Primary Care Association, KY

Step 1:

Member Info

Company Name *

Please add your company name.

Phone *

Please add your company phone number.

Website

Email *

Please add a valid email.

Physical Address

Address line 1 *

Please add your address.

Address line 2

City *

Please add your City.

State *

Please add your MN.

Postal Code *

Please add your Postal Code.

Country *

Please add your country.

Mailing Address

Same as physical address

Address line 1 *

Please add your address.

Address line 2

City *

Please add your City.

State *

Please add your MN.

Postal Code *

Please add your Postal Code.

Country *

Please add your country.

Step 2:

Additional Info

Business Description *

Please add your company description.

Business Keywords (enter a space between words)

IPA *

Looks good!

Clinic Type (RHC, FQHC, other) *

Looks good!

If ''other'', please describe here

Oral Health

EHR System *

Looks good!

Clearinghouse *

Looks good!

Vision

Behavioral

Step 3:

Primary Contact

First Name *

Please add your first name.

Last Name *

Please add your last name.

Title

Phone *

Please add your phone number.

Cell Phone

Fax *

Please add your fax number.

Email *

Please add a valid email.

Contact Preference

Phone

Address

Same as Address in Step 1

Address line 1 *

Please add your address.

Address line 2

City *

Please add your City.

State *

Please add your State.

Postal Code *

Please add your Postal Code.

Country *

Please add your country.

Create Account

Password *

Please add your login password.

Step 4:

Billing Contact

Same as Primary Contact

First Name

Last Name

Title

Phone

Cell Phone

Fax

Contact Preference

Phone

Address

Address line 1

Address line 2

City

State

Postal Code

Country

Create Account

Password

Step 5:

Membership Package

Please select a Membership Package

FQHC/RHC Entity $1,000.00

$2,000,001 or more in operating expenses

FQHC/RHC Entity $750.00

$500,001 to $2,000,000 in operating expenses

FQHC/RHC Entity $500.00

Less than $500,000 in operating expenses

Organizational Membership $480.00

Over 50 Employees

Organizational Membership $320.00

26 - 50 Employees

Organizational Membership $200.00

0-25 Employees

Individual $20.00

Payment Option

Bill Me

Please complete the Captcha

Back Next Submit Application Print Application

Member Application

Step 1:

Member Info

Physical Address

Mailing Address

Step 2:

Additional Info

Step 3:

Primary Contact

Address

Create Account

Step 4:

Billing Contact

Address

Create Account

Step 5:

Membership Package

Payment Option

Upcoming Events