Membership Application

Before You Start

Be sure you have reviewed CCALAC Membership Criteria and have the following documents ready before you start the CCALAC membership application:

Articles of incorporation
Federal Tax Exemption as 501(c)3
Bylaws
Written policy of non-discrimination on ability to pay/sliding fee scale
Current state licenses for each clinical site
Most recent financial audit
Two (2) most recent HCAI Reports
Most recent IRS form 990
Electronic logo

Please complete the application and attach all required documents.

CCALAC Membership Dues

Annual Dues as Percentage of Clinic Budget is 0.18 %
Annual Dues Cap is $40,000

If you have any questions, please contact Lisa Fisher, Vice President of Member Relations.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Clinic Information

Clinic Name*

Mission Statement*

Licensed Since (if applicable)

MM slash DD slash YYYY

Website

Staff Size*

Is your clinic a Federally Qualified Health Center?*

Yes

If yes, please indicate your agency's designation*

Have you achieved PCMH Status?*

Do you have any teaching or residency programs within your agency?*

Which EHR do you use?*

What type of Pharmacy do you have?*

Full Pharmacy

Dispensary

Both

None

Please list any hospitals you are affiliated with:

Clinic Director*

Prefix First Last Suffix

Please specify "other"*

Clinic Address If your clinic has multiple locations, please list administrative office location here.

Street Address Address Line 2 City State ZIP Code

Additional Clinic Site*

Yes

Directory of All Clinic Locations*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Please upload a directory of all you clinic locations. Upload as doc, docx, or pdf file

Articles of Incorporation*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Copy of Bylaws*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

List of Board of Directors, with officers noted*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Contact Information

Name*

Prefix First Last Suffix

Title*

Phone*

Email*

Enter Email Confirm Email

Address*

Same as Above

Differant than Above

Address*

Street Address Address Line 2 City State ZIP Code

Financial Information

Federal Tax ID #*

Federal tax exemption as 501(c)3*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Copy of most recent financial audit*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Copy of most recent IRS form 990*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Fiscal Year End*

Indicate month your clinic's fiscal year ends.

Total Expenses (per your latest Health Care Access and Information - HCAI )*

Copies of two (2) most recent Health Care Access and Information (HCAI) reports*

Drop files here or

Accepted file types: doc, docx, pdf, xls, xlsx, Max. file size: 24 MB.

Upload as doc, docx, xls, xlsx, or pdf file

Clinic Operations

Written policy of non-discrimination on ability to pay/sliding fee scale*

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Please provide the names, phone numbers and emails of your staff who having the following responsibilities

Chief Financial Officer

Chief Financial Officer*

Prefix First Last Suffix

Title (if different)

Chief Financial Officer Phone*

Chief Financial Officer Email*

Enter Email Confirm Email

Medical Director

Medical Director*

Prefix First Last Suffix

Title (if different)

Medical Director Phone*

Medical Director Email*

Director of Nursing

Director of Nursing

Prefix First Last Suffix

Title (if different)

Director of Nursing Phone

Director of Nursing Email

Enter Email Confirm Email

Director of Pharmacy

Director of Pharmacy

Prefix First Last Suffix

Title (if different)

Director of Pharmacy Phone

Director of Pharmacy Email

Enter Email Confirm Email

Operations Director

Operations Director

Prefix First Last Suffix

Title (if different)

Operations Director Phone

Operations Director Email

Enter Email Confirm Email

Human Resources (HR) Director

HR Director

Prefix First Last Suffix

Title (if different)

HR Director Phone

HR Director Email

Health Information Technology (HIT) Manager

Health Information Technology (HIT) Manager

Prefix First Last Suffix

Title (if different)

Health Information Technology (HIT) Manager Phone

Health Information Technology (HIT) Manager Email

Name of electronic health record (EHR) system your clinic uses:*

Partnerships

Is your clinic a member of the California Primary Care Association (CPCA)?*

Yes

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Letter of Recommendation from CCALAC member in good standing in the same Service Planning Area (SPA) - One of Two

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

This field is hidden when viewing the form

Letter of Recommendation from CCALAC member in good standing in the same Service Planning Area (SPA) - Two of Two

Accepted file types: doc, docx, pdf, Max. file size: 24 MB.

Upload as doc, docx, or pdf file

Narrative

Briefly describe:

(1) history and development of your clinic (i.e., how it got started and by whom, involvement of the local community, its growth and development, etc.);
(2) how your clinic implements its mission statement;
(3) the enabling services (e.g. transportation, translation, etc.) provided in addition to primary care; and
(4) consumer (patient) involvement.

Limit: 9,000 characters*

Clinic Logo*

Accepted file types: jpg, png, gif, Max. file size: 24 MB.

Marketing Materials

Drop files here or

Max. file size: 24 MB.

CCALAC Member Agreement

This is to certify that the below signed as the Member Delegate whose signatures appear below, is an official delegate of the clinic organization listed on this application to the Community Clinic Association of Los Angeles County (CCALAC). The Primary and Alternative delegates listed above have their primary employment at our agency and have no conflict of interest with other CCALAC Member agencies. If there is a change in our delegates, a written notification will be sent to CCALAC. This also represents our clinic's agreement to the activities of the Association. It is understood that all information provided will be treated with confidentiality.*

Use mouse to sign form

Signatory Name*

First Last

Signatory Title*

Date*

MM slash DD slash YYYY

Health Care Program Affidavit

Is your clinic or any member staff member barred from participation in a funded health care program?*

Yes

The clinic listed on this application hereby certifies that itself nor any of its staff members are currently barred from participation in a federally funded health care program, whether such bar is direct or indirect, or whether such bar is in whole or in part.*

Use mouse to sign area above

Signatory Name*

First Last

The clinic listed on this application hereby certifies that itself and/or one or more of its staff members is/are currently barred from participation in a federally funded health care program, whether such bar is direct or indirect, or whether such bar is in whole or in part.*

Use mouse to sign area above

Signatory Name*

First Last

The following describes the details of the exclusionary action(s):*

Submission

Upon approval of the CCALAC board of directors, CCALAC will send an invoice for dues to the primary contact listed on this application. Member dues rate determinations are based on total reported on the most recent Health Care Access and Information (HCAI) operating expenses across all clinic sites located in Los Angeles County.

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