IHCA/INCAL Facility Membership Application

Important Reminders

IHCA/INCAL’s facility membership is available for Indiana’s skilled nursing facilities and assisted living communities. The membership benefits can be enjoyed by all facility employees and staff in your corporate office.

Eligibility Criteria

The IHCA/INCAL Regular “A” membership is available to:
- health care facilities licensed under Indiana Code 12 or 16, or applicable successor statutes, and
- facilities not subject to licensure and serving the elderly, such as independent living and adult day care.
A person or entity having at least 50% of the control or authority over more than one (1) facility eligible for membership must submit an application for all facilities over which the control or authority is exercised.

Dues Information

Dues are collected by IHCA/INCAL on behalf of our national membership organization, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).
Dues amounts set forth below do not include any applicable discount provided by the IHCA, INCAL, AHCA or NCAL.
Dues will be collected from the applicant upon approval of membership by the IHCA Board of Directors and according to the IHCA Dues Collection Policy.
Any applicable discounts will be applied to dues invoices.

IHCA/INCAL Facility Membership Application

If you experience trouble submitting your entry, please contact Deeksha Kapoor at dkapoor@ihca.org.

Step 1 of 7

Facility Information

Facility Name

Address

Street Address Address Line 2 City State ZIP / Postal Code

Fax number

Phone

Website

Bed Type

Licensed Residential Care Beds, Unlicensed Assisted Living, and Independent Living Beds

Comprehensive Care Bed Type

(all types – SNF/NF, SNF, NF, NCC)

Total Capacity

Billing Contact Information

Use the "plus sign" on each field to add a row to input additional contacts.

First and Last Name of Billing Contact

Position

Phone Number

Email Address

Please describe your accounts payable process, and include whether invoices are to be sent to the corporate office or to the facility.

Key Facility Staff Information

IHCA/INCAL offers a wealth of resources that are exclusively developed for our members. To maximize your membership benefits, it is important that you provide us with the contact information of key staff members of your facility who should receive access to IHCA/INCAL's suite of digital communications resources including a self-serve member portal, e-newsletters, toolkits, on-demand education offerings, and more.

Administrator Name

First Last

Administrator Email

Medical Director Name

First Last

Medical Director Email

DON Name

First Last

DON Email

Social Services Name

First Last

Social Services Email

HR Director Name

First Last

HR Director Email

Dietary Manager Name

First Last

Dietary Manager Email

Maintenance Director Name

First Last

Maintenance Director Email

Other Facility Contacts

Please click on the "plus" sign to add a row next to each field and input contact information of other key staff members who should receive access to IHCA/INCAL's suite of digital communications and resources.

First Name

Last Name

Title

Email Address

Corporate Information

Name of Operating Entity

Does your organization classify as a not-for-profit organization?

Yes

Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone

Fax number

Website

Corporate Leadership Contact Information

President/CEO Name

First Last

President/CEO Email

Other Key Corporate Leadership Contact Information

Please click on the "plus" sign to add a row to input contact information of each key corporate staff member who should receive access to IHCA/INCAL's suite of digital communications and resources.

First Name

Last Name

Title/Designation

Email Address

Agreement and Payment

I attest to the accuracy of the information on this application and understand that submission of this application is not a guarantee of IHCA membership and that this application must be approved by the IHCA Board of Directors. I understand that membership benefits are only to be used by the applicant and its employees and that any misuse of membership rights and benefits may result in membership termination. I agree to abide by all policies of the IHCA, including, but not limited to, the IHCA Dues Collection Policy. If this application is approved, I permit IHCA to use the information contained in this application in IHCA membership directories (both electronic and printed), and I consent to receive communications via regular mail, email, telephone, and/or fax sent by or on behalf of IHCA. IHCA dues are not deductible as charitable contributions for tax purposes, but may continue to be deductible as a business expense. However, per Section 6033(e) of the Internal Revenue Service Code, a reasonable estimate of IHCA dues will be spent on lobbying and other expenditures subject to Section 162(e)(1) of the Code and therefore are not deductible for federal income tax purposes. A reasonable estimate of 3% of IHCA/INCAL dues and 30% of AHCA/NCAL dues in 2023 will be spent on lobbying and other expenditures subject to Section 162(e)(1) of the code, and therefore are not deductible for federal income tax purposes.

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Facility Membership Application

IHCA/INCAL Facility Membership

Important Reminders

Eligibility Criteria

Dues Information

Dues Structure

IHCA/INCAL

AHCA/NCAL

IHCA/INCAL Facility Membership Application

Facility Information

Bed Type

Billing Contact Information

Key Facility Staff Information

Other Facility Contacts

Corporate Information

Corporate Leadership Contact Information

Other Key Corporate Leadership Contact Information