Phone

(215) 676-7940

DVHCC Member Form Application

All applications for membership and renewal of membership are subject to approval by the DVHCC Board of Directors and contingent upon receipt of a check for Seven Hundred Fifty ($750.00) dollars representing the one-time initiation fee of Five Hundred ($500.00) dollars and the first year’s annual dues of Two Hundred Fifty ($250.00) dollars. Please make your check payable to the Delaware Valley Health Care Coalition, Inc.

By completing this application, you hereby represent that you have the legal authority to bind your organization; and hereby agree as follows:

  1. To adhere to the obligations of Members of the Delaware Valley Health Care Coalition, Inc. in conformance with the Articles of Incorporation, By-Laws, and their Amendments, as well as any and all Resolutions passed by the Board of Directors of the Coalition.
  2. To pay all applicable utilization fees as determined by the Delaware Valley Health Care Coalition Board of Directors as set forth in all vendor contracts that our organization becomes signatory to and receives such benefits of while continuing to maintain membership in the Coalition.
  3. Further, as a Member of this Coalition, our organization acknowledges and agrees that if our organization fails to maintain “good standing” membership in the Delaware Valley Health Care Coalition, Inc. and continues to receive any pricing, discounts, rebates and/or quality services set forth in any Umbrella contract and/or Member Agreement to which our organization is signatory, then the DVHCC has the right to charge our organization an “access fee” equivalent to the normal utilization fees owed under the vendor contract based upon our organizations’ past year’s utilization for so long as our organization continues to receive such Coalition-negotiated benefits.
  4. Further, it is the understanding of our organization that the Coalition has the right and obligation to collect any access fee or utilization fees either directly from the Vendor or Member should the Vendor fail to properly collect the utilization fees and remit the same to the Delaware Valley Health Care Coalition.
  5. As a Member of this Coalition, our organization acknowledges and agrees that in order to determine the vendor’s compliance with the terms of the contract and affiliated Member Fund agreements, the Coalition has the authority to acquire from all vendors certain de-identified, summary information and reports, provided that the information is consistent and in compliance with the provisions of the “Privacy Rule” (set forth in 45 CFR Part 164) of HIPAA.

Organization

Contact Person

Contact Person Name

Contact Person’s Title

Is Contact A Third-Party Administrator?
YesNo

If Yes, TPA Firm

Address

City

State

Zip

Phone

Cell/2nd Phone

Fax

E-Mail

Employee Identification Number

Fund Participants

Active Members

Active Members’ Dependents

Retired Members

Retired Members’ Dependents

Total Participants

Consultant/Actuary

Consultant/Actuarial Firm

Medical Carrier

Medical Carrier Name

Insured Or Self-Insured?

Medical Renewal Date

Stop-Loss Provider

Stop-Loss Renewal Date

Typical Hourly Welfare Fund Contribution Rate (in Dollars)

Retiree Medical Carrier

Retiree Medical Carrier Name

Pre-65

Insured Or Self-Insured?

Medicare Eligible

Insured Or Self-Insured?

Pharmacy Benefit Manager

Pharmacy Benefit Manager Name

Insured Or Self-Insured?

Pbm Renewal Date

If You Cover Medicare-Eligible Participants, Are They Enrolled In Either RDS or EGWP Programs?

YesNo

RDS

EGWP

Dental Carrier

Dental Carrier Name

Insured Or Self-Insured?

Dental Renewal Date

Life Insurance Carrier

Life Insurance Carrier Name

Insured Or Self-Insured?

Life Renewal Date

Vision Carrier

Vision Carrier Name

Insured Or Self-Insured?

Vision Renewal Date

Fiduciary Insurance Carrier

Fiduciary Insurance Carrier Name

Fiduciary Insurance Renewal Date

Future Issues You Would Like The Dvhcc To Address

Notes/Additional Information