Fill-out the application online below or click here to download a copy.

Name of Facility:*
Address of Facility: *
Phone:*
-
Fax:
Administrator:
E-mail:*
Is your facility Accredited by:
(list date of inspection)
Your facility must be certified by Medicare to be a member of IASCA. If your status is pending please list your date of inspection:
Number of dedicated operating rooms:

OWNERSHIP INFORMATION

Choose one:
If Other, please specify:

To determine dues, follow the formula below:

Number of patients handled by your facility in 2016 (Jan – Dec) _________ x  $0.30 =  $_________

Minimum Dues $300  

We are also asking that each facility Administrator and physician owner become Associate member at $350.00 each.   

Those will be listed below.

Nursing Director:
Nursing Director E-mail:
Medical Director:
Medical Director E-mail:

Mailing/Listing Information

Where do you want IASCA mail delivered?
Where do you want IASCA e-mail delivered?
Which address should be listed in the directory?
Center Name:
Owner list, Name & Email:
Number of patients in 2016
X .30 cents = $
Number of Associate members for 2017
X $350 = $
Total dues for 2017 $

Credit card information:

Card number:
Expiration Date:
3 or 4 digit code on the back of card:
Address statement for this card is mailed to:
Name on Card:
Electronic Signature: