PACE Organization Membership

Please note that required questions are marked with an *

Your Individual Contact Information

Full Name, including Postnominals (like RN, MD, MPA, etc.)*

Job Title*

Email Address*

Preferred Phone Number (Direct Line/Extension/Mobile Phone)*

How did you hear about NPA?

Member Organization Profile Information

Preferred Organization Name*

The preferred name that the organization uses to market itself to the general public.

Legal Organization Name (if different)

Full Physical Address of PACE Center (including city, state and zip)*

This is the address that will geo-locate in our online PACE Finder, which helps drive enrollment referrals from visitors to our website looking for their local PACE.

Full Mailing Address of Organization (if different from above)

Main Phone Number*

This is generally a main administrative office phone number.

Enrollment Phone Number (if different)

If you have a different phone number for enrollment inquiries, list that here. This is the phone number we will use for the general public in our online PACE Finder.

TTY Number

Enrollment/Marketing Inquiries

Do you also have an enrollment/marketing specific email that you would like us to include for referrals? This is normally something like info@pace.org or referrals@pace.org.

Website or Webpage for Organization*

What type of legal structure does your PACE organization have?*

A stand-alone legal entity with no corporate members

A stand-alone legal entity with corporate member or members (parent or sponsoring organizations)

It is a service or business line of a larger organization and not its own legal entity

It is one of the above, but we are managed by another organization under a management agreement

Other...

Organization Tax Status

EIN

H Number

This is a number, typically in the format H1234, that is assigned by the Centers for Medicare & Medicaid Services (CMS).

CMS Contract Date*

Date Opened/Began Serving Participants*

Staff List for Membership Benefits

Our memberships are done on an organizational basis. Once your organization is approved as a member, all of the benefits of membership are available to your entire staff. In order for them to take advantage of their member benefits, they'll just need an NPA account.

How would you like to add your staff*

I will upload a staff list below

I'll do a list, but reach back out to me in a bit for it

I'll have them create their own (you'll tell me how after our membership is approved)

Other...

Other Staff Contacts

If you are creating a list, we'll need the same information that we asked for you above (full name, postnominal, job title, email, preferred direct phone number). Or, if it's easier for you, feel free to upload an existing staff roster. Word and excel files preferred, but we can also accept PDF files.

Current State of PACE Program

This information is optional, but helps us to better serve you and your organization's particular needs.

Are there any particular challenges you are facing, member benefits or services that you are particularly interested in, or do you have other top of mind needs that prompted you to join at this time?

A year from now, what would you have gained from the membership that would cause you to look back and consider it a good return on your investment?

Ready to Submit?

I accept NPA's member code of conduct.*

Yes

I accept NPA's antitrust policy and guidelines.*

Yes

Review Code of Conduct and Antitrust

If your state has a chartered state PACE association, NPA has a mutual membership agreement. NPA and SPAs work closely together.*

My PACE program is located in CA, FL, MA, MI, NC, NJ, PA, RI, TX or VA and we are a member of our state PACE association

My state doesn't yet have a state PACE Association

PACE "multis" are defined as 3 or more PACE organizations delineated by CMS H number, which are under common control (ownership of 50% or more) OR common management (defined as consolidated authority over financial decision-making). If my PACE program/H number is part of a "multi", I understand that all must be a member of NPA for me to be eligible.*

No, my PACE organization is not a multi under this definition.

Yes, I can attest that all PACE organizations of my multi are already NPA members.

Your membership application must first be approved, and then you will be invoiced. NPA's annual membership year runs from July 1-June 30. If you apply during the year, your membership will be pro-rated for the rest of the membership year, and billed annually thereafter. Membership in NPA will not begin until payment in full is received. Membership is non-refundable. Please signal your acceptance by checking "yes" below.*

Yes

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PACE Organization Membership