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FACILITY MEMBERSHIP APPLICATION

Membership is available to ASCs in operati on and those in development. Open ASCs must be accredited, Medicare certi fi ed, reimbursed
by insurers as an ASC or state licensed. Please send proof of one of these with your applicati on, if applicable.
ASCA Member on In today’s health care environment, hard work The ASCA website is our member informati on hub. It oﬀ ers you a centralized portal for criti cal informati on, FACILITY NAME _________________________________________ ❑ ASC in Development $599

ASCA’s Advocacy: and good intenti ons are not enough to keep resources and tools designed to help you manage your daily operati ons eﬀ ecti vely. ADDRESS ______________________________________________ ❑ Introductory Rate $599
• New to ASCA & have not held ASCA membership prior to 2014
your ASC profi table. You need to be current
• Requires proof of ASC Status.
Access all of these resources at the click of a mouse at www.ascassociati on.org!
“ASCA goes to the with best practi ces, compliant with the most EDUCATION: INFORMATION: CITY __________________________________________________ • REQUIRED: Number of pati ent visits in 2017 (or last 12
STATE __________________________ ZIP ___________________
months) _________________________________________
recent regulati ons and aware of the issues
Capitol to represent that impact your bott om line. ASCA meeti ngs and webinars provide your enti re team Stay ahead of regulatory and legislati ve developments FACILITY PHONE ________________________________________ ❑ ASCA All-Access Member Bundle $1,243
Special Off er: Subscribe to both 2018 Webinar All-Access Pass AND
and get armed with strategies that will help you stay
with vital informati on and tools to respond to the
ASCs on our behalf. Membership in ASCA will: trends and issues aﬀ ecti ng the ASC community, keep compliant and meet and exceed the highest standards FACILITY FAX ___________________________________________ ASCA Benchmarking 2018 to reduce your membership dues to $549
and the ASCA Benchmarking price to $299.
FACILITY EMAIL _________________________________________
of pati ent care.
costs in check and raise pati ent sati sfacti on levels to
There may be diﬀ erent ENSURE YOUR EMPLOYEES ARE CONNECTED new highs. FEDERAL REGULATIONS: WEBSITE ______________________________________________ ADDITIONAL SUBSCRIPTIONS:
AND INFORMED WITH:
❑ Please check this box to subscribe to ASCA Benchmarking 2018.
❑ SINGLE SPECIALTY ❑ MULTI-SPECIALTY
things that CMS • A trusted community of fellow ASC professionals EDUCATION & EVENTS: • Medicare Payment Resources CHOOSE ALL THAT APPLY: Four a quarter access begins April 1st for $329.
to learn from and share interest with ASCA
• 2018 ASCA’s annual meeti ng
• Medicare Rate Calculator
BENCHMARKING ADMINISTRATOR: ________________________
att empts to impose • Weekly e-news updates on ASC trends, issues • Past webinars and conference recordings • Medicare Conditi ons for Coverage ❑ CARDIOLOGY ❑ ORTHOPEDIC/HAND EMAIL: ________________________________________________
Connect
❑ ENT
❑ PAIN MANAGEMENT
• HIPAA Requirements – FREE HIPAA Manual
and ASCA is there to and best practi ces that you can apply in your • Winter Coding, Infecti on Preventi on and Business • Quality Reporti ng ❑ GASTROINTESTINAL ❑ PLASTIC SURGERY ❑ 2018 Webinar All-Access Pass with CE Credits ($399) is available to
seminars
all ASC staﬀ members and includes live and on-demand access. Please
❑ PODIATRY
❑ GENERAL SURGERY
• Electronic Health Record FAQs
practi ce
speak on our behalf, • ASC Focus magazine, in print and/or digital • 2018 Webinar All-Access Pass GOVERNMENT ADVOCACY: ❑ GYNECOLOGY/OBSTETRICS ❑ UROLOGY provide the name and email address for the staﬀ member who should
receive the monthly login informati on for the webinars. Webinar
• ASCA’s Online Training Series, provided by
❑ OTHER____________________
package will be processed separately if paying via credit card.
❑ NEUROLOGY/NEUROSURGERY
format, to access member-driven, cutti ng-edge
explaining how some content HealthStream • Legislati ve News ❑ ORAL/DENTAL SURGERY __________________________ NAME: ________________________________________________
• Government Aﬀ airs Update, including past issues
Membership has decisions aren’t GUARANTEE YOUR ORGANIZATION STAYS UP RESOURCE CENTER: • State Resource Center, including ASCA’s State Law As a facility member, any employee of your ASC can purchase GRAND TOTAL $__________
EMAIL: ________________________________________________
items and att end seminars at the member rate.
Database
TO DATE WITH:
Access robust tools that will help you and others at your
its advantages applicable to ASCs and • Discounts on ASCA’s Benchmarking, clinical ASC gain the knowledge and resources you need to take GRASSROOTS ADVOCACY: The ASCA Voti ng Representati ve is the ASCA primary contact. REFERRAL:
your skill set to the next level, improve your producti vity
1. VOTING REPRESENTATIVE _______________________________
and operati onal survey, to compare your data
why CMS needs to with nati onal performance stati sti cs on clinical and further your professional growth. GET INVOLVED, TAKE ACTION TITLE _______________________________________________ HOW DID YOU HEAR ABOUT ASCA? __________________________
• ASCA’s Capitol Fly-In
outcomes
• Clinical and operati onal benchmarking survey
take the legislati on in a • Weekly government aﬀ airs e-newslett ers • ASC Salary and Benefi ts Survey • ASCAPAC 2. DESIGNATED REP ______________________________________ NAME OF REFERRAL _______________________________________
EMAIL ______________________________________________
• Issue Briefs
ASC REFERRAL _____________________________________________
with the latest informati on on legislati ve and
regulatory issues aﬀ ecti ng your practi ce
ASCA is the only nati onal associati on dedicated to advancing diﬀ erent directi on .” • Medicare quality reporti ng informati on and • Resource Library NETWORKING ONLINE: TITLE _______________________________________________ FORM OF PAYMENT:
• Career Center
ASCA Connect is ASCA’s members-only, online
❑ VISA ❑ MASTERCARD ❑ AMEX
the goals and addressing concerns of the industry – and of – Cindy Young, BSN, RN, CASC ASCA’s Medicare Rate Calculator • ASCA Focus magazine, including past issues community for ASC professionals. There, you can get EMAIL ______________________________________________ by faxing invoice and proof, if applicable, to 703.828.0963
real-world answers to your questi ons and concerns
Administrati ve Director • ASC News Digest, including past issues from your colleagues around the country at a moment’s 3. MEDICAL DIRECTOR____________________________________
ASC professionals like you. ASCA provides all ASCs with the HELP YOUR EMPLOYEES ADVANCE THEIR • Drug Shortage Informati on Center noti ce. Join ASCA today and join the conversati on! CARD NO:
CAREERS THROUGH: EMAIL ______________________________________________
advocacy support and resources they need to conti nue to • Professional development from the comfort of • Aﬃ liate Business Directory EXP. DATE CVV
their own desks from up to 17 webinars, live 4. ADMINISTRATOR ______________________________________ CARD HOLDER NAME ____________________________________________
deliver high-quality care and pati ent-focused surgical services. and on-demand, with conti nuing educati on EMAIL ______________________________________________
credit hours ASCA Member on ASCA Connect: 5. ASCA BILLING CONTACT ________________________________ SIGNATURE ____________________________________________________
Take advantage of ASCA’s benefi ts to obtain CEUs, • Member discounts on ASCA’s annual meeti ng, “ I’m on that thing every day to TITLE _______________________________________________ ❑ Pay by mailing a check made payable to ASCA with invoice
and proof, if applicable, to:
the largest meeti ng in the ASC industry, as well
benchmark clinical operati ons, connect with colleagues, get as, coding and other business-related seminars EMAIL ______________________________________________ ASCA
PO Box 75066
• ASCA’s online training series, provided by see what the questi ons are. I love Balti more, MD 21275-5066
updates on trends and issues and stay ahead of regulatory HealthStream, to stay up-to-date on compliance 6. CODING MANAGER ____________________________________
issues and mandates. TITLE _______________________________________________ FOR ADMINISTRATIVE USE ONLY:
requirements. contributi ng to it, and I learn so much EMAIL ______________________________________________ ENTERED ON: ________________ BY: _______________ NEW2017
from my colleagues.” – Dianne Appleby, RN, BSM, MBA Dues payments to ASCA are not tax deducti ble as charitable contributi ons for federal income tax purposes. However, they may be deducti ble as ordinary and
necessary business expenses subject to restricti ons imposed as a result of ASCA’s lobbying acti viti es. ASCA esti mates that the nondeducti ble porti on of your
Executi ve Director/Administrator 2018 dues — the porti on that is allocable to lobbying — is 21%.

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