NSCHBC Membership Application

Application Fee $125.00

Annual Membership Dues $650.00

Please note that all fees and dues are non-refundable.

* = REQUIRED
First Name: *
Last Name: *
Accreditation/Certification/License:
(i.e. CPA, EA, RN, etc.)
Highest Academic Achievement: *
(i.e. BS, BA, MBA, PhD, MD, DDS, DO, etc.)
Company Name (or your current employer): *
Is anyone at your company currently a NSCHBC Member? Yes   No
If yes, please list:
Title: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Telephone: *
Fax:
E-mail Address: *
Website URL: http://
Select the statement below which best describes your business: *
I provide independent business/management consulting and related professional services to healthcare professionals and/or organizations.
I am an employee of a practice or organization that provides healthcare services.
My time is split between each activity in the following percentage breakdown:
  • Independent business/management consulting and related services: %
  • Employee of a practice or organization that provides healthcare services: %
How long have you been engaged in providing business/management consulting and related professional services to healthcare professionals or organizations at the time of this application? *
Approximately how many practices or organizations of each type do you personally serve?
Physicians Practices *
  Collectively, how many physicians does this involve?  
What percentage of your time do you spend in this activity?  
Dental Practices *
  Collectively, how many dentists does this involve?  
What percentage of your time do you spend in this activity?  
Hospitals *
  Describe the type of work you do in your hospital engagements.

What percentage of your time do you spend in this activity?  
Other Healthcare Organizations *
  Describe the types of organizations and the nature of your engagements.

What percentage of your time do you spend in this activity?  
Non-Healthcare *
  Describe the type(s) of organizations you serve and the nature of your engagements.

What percentage of your time do you spend in this activity?  
Choose the five areas below that best represent the nature of your engagements/work and expertise: *
Accounting
Audits - General
Audits - Embezzlement
Audits - Medical Records
Audits - Medicare/caid
Administrative Recruitment
Ambulatory Surgery Centers (ASCs)
Architecture/Office Real Estate
Asset Protection
Billing
Brokerage (Licensed)
Business Opportunity Analysis
Capitation
CLIA and Laboratory
Compensation
Competitive Analysis
Compliance Reviews
Contracts
Credentialing
Demographic Analysis
Electronic Healthcare Records
Facility Selection
Feasibility Study
Financial Planning
Forensic Accounting
Governance
HIPAA
Hospital and/or PHO Devel
Image Development
IPA
Information Technology
Insurance
Joint Ventures
Law - Business (Licensed)
Law - Contracts (Licensed)
Law - Labor (Licensed)
Law - Malpractice (Licensed)
Law - Other (Licensed)
Litigation Support
Managed Care
Marketing/PR/Branding
Media Services
Mergers/Acquisitions (Licensed)
Mergers/Acquisitions (Unlicensed)
Metrics/Analytics
MSO
OSHA/Workplace Safety
Outcomes Study Devel/Mgmt
Patient Information Education
Patient/Community Relations
Patient Satisfaction Surveys
Patient Scheduling/Flow
Pension/Profit Sharing
Personnel Development
Personnel - HR Issues
Portfolio Management
Practice Mgmt - Chiropractic
Practice Mgmt - Dental
Practice Mgmt - Medical
Practice Mgmt - General
Practice Mgmt - Physical Thrpy
Practice Mgmt - Podiatric
Practice Mgmt - Optometric
Practice Surveys
Professional Corp Issues
Public Speaking Seminars
Publications
Quality Assessment
Recruitment - Dentists
Recruitment - Nurses
Recruitment - Paraprofessional
Recruitment - Physicians
Recruitment - Staff/Mgmt
Reimbursement - Coding
Reimbursement - Billing
Reimbursement - Other
Retirement/Estate Planning
Risk Assessment
Rural Health Clinics
Sale/Purchase (Licensed)
Sale/Purchase (Unlicensed)
Skilled Nursing Facilities
Software Development
Start-ups/Closures
Strategic Planning
Taxes
Training
Utilization Review
Valuation
Please identify up to six states in which you and your firm provide services. *
If you have been in your current position for less than five years, please list any prior experience in providing healthcare business/management consulting and related professional services (either as a third party advisor or employee of a healthcare organization):
  Firm Location Position Phone Number Years of Experience
1.
2.
3.
Have you or any company or organization for which you have been employed ever been convicted of Medicare/Medicaid Fraud? *
Yes   No
Do you or your firm sell products and/or investments to your clients? *
Yes   No
If yes, please list:
If yes, do you provide a full disclosure?   Yes   No
If no, please explain:
Do you receive any income in the form of a commission or rebate from a third party? (Including but not limited to insurance companies, investment sales organizations, equipment manufacturers, suppliers, attorneys, or architects.) *
Yes   No
If yes, please list:
If yes, do you provide a full disclosure?   Yes   No
If no, please explain:
How did you hear about the NSCHBC? *
NSCHBC Current Member
      (Please list: )
Non-NSCHBC Member
Google Search
WebMD/Medscape
Modern Healthcare
Other Online Journal
NSCHBC Social Media Pages
Other
      (Please list: )
Do you know any current members of the NSCHBC? *
Yes   No
If yes, please list by name and years of acquaintance:

Acknowledgement

I have reviewed the Society's code of ethics prior to completion of this application. It is expressly agreed that should I terminate (or be terminated) from membership in the National Society of Certified Healthcare Business Consultants for any reason, use of the Society logo and other identifying data will be discontinued immediately.

I understand that a non-refundable application fee of $125.00 must be included with my completed application.

I understand that in order to be accepted as a member in the National Society of Certified Healthcare Business Consultants, my application must be reviewed for membership submission. I understand that new members must attend an educational meeting within three years of joining the Society.

I represent that the foregoing responses are factual at the time of this application and that they are presented on a basis for the consideration of my membership application.

Name:  
Date:   

Payment

Application Fee: $125.00
Please charge my        American Express      MasterCard      VISA
Cardholder name
Credit card number:
Expiration date: /


Please mail payments made by check to:

NSCHBC
12100 Sunset Hills Road
Suite 130
Reston, VA 20190

Please note that all fees and dues are non-refundable.