WASCA Membership Application - Facility Membership

Facility Membership

PLEASE NOTE: If you plan on paying by check, please print and complete this form and send it in with your payment instead of filling out the form below.

PLEASE NOTE: For Facility Membership, please identify the ASC as the member and not the physician practice that owns the ASC. For more information, please see Categories of Membership.

Name of Facility*

Address of Facility*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Website

Owner(s)

Please list the name(s) of the owner(s), along with the % owned by doctor, hospital, or other.

Accreditation and Certification

AAAHC
AAAASF
The Joint Commission
Medicare

If yes to Medicare, please provide the Medicare #

State Licensure

Licensed
Exempt

If licensed, please provide the license #

Facility Type

Single Specialty
Multi-Specialty

If single specialty, please list the specialty

Personnel
Please update the email addresses for the positions noted at your ASC facility. As a WASCA member, all employees have access to the member listserv. If there are additional employees who would like to join the listserv, please contact info@wasca.net.

Administrator Name

First Last

Administrator Email*

Business Manager Name

First Last

Business Manager Email

Clinical Director Name

First Last

Clinical Director Email

Materials Manager Name

First Last

Materials Manager Email

Medical Director Name

First Last

Medical Director Email

Facility Membership Fee Schedule*

New members receive a 50% discount the first year of membership.

New Member

I am joining WASCA for the first time

Fee Schedule*

2,500 or more cases per year per center - $3,161
1,000 or more cases per year per center - $2,106
500 or more cases per year per center - $1,581
ASC Not Yet Operational - $741
Single Physician Owned Center under 500 cases per year - $840

Fee Schedule New Member*

2,500 or more cases per year per center - $1,505
1,000 or more cases per year per center - $1,053
500 or more cases per year per center - $790.50
ASC Not Yet Operational - $370.50
Single Physician Owned Center under 500 cases per year - $420

As a new or renewing member of WASCA, I will make a $1,000 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $1,000 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $500 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $500 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $300 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $300 contribution to WASC PAC

As a new or renewing member of WASCA I will make a $250 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $250 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $100 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $100 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $1000 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $1,000 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $500 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $500 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $300 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $300 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $250 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $250 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $100 contribution to WASC PAC

As a new or renewing member of WASCA, I will make a $100 contribution to WASC PAC

PAC Contribution $1000

Price:

PAC Contribution $500

Price:

PAC Contribution $300

Price:

PAC Contribution $250

Price:

PAC Contribution $100

Price:

Fees are due upon joining and are billed annually.

*Pursuant to IRS code section 6033(e), WASCA hereby provides notice that 45% of membership dues will be allocated to lobbying activities in 2025. As such, 45 % of your dues paid to WASCA are considered non-deductible.

TOTAL

$0.00

Credit Card

American Express

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MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

INQUIRIES: Contact the WASCA office at info@wasca.net.

WASCA Membership Application – Facility Membership

Facility Membership

Facility Membership Fee Schedule*

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