Membership Application - New Mexico Coalition for Healthcare Value

New Mexico Coalition for Healthcare Value Membership Application

Thank you for your interest in the New Mexico Coalition for Healthcare Value. Please complete the form below regarding your organization’s New Mexico operations. Having a better picture of the characteristics of coalition members gives the Board of Directors and Committees a clearer idea of what would be of most value to members. Once submitted, this application goes before the Board of Directors for approval. Once approved, your organization will be invoiced for dues.

If you wish to fill out a PDF version of our membership application, please click the link below to download the form and email the completed copy to: swilson@nmhealthcarevalue.org

Download PDF Version of the Membership Application

Name of Organization*
Address*
Street Address Address Line 2 City State ZIP Code
Primary Contact*
Title*
Phone*
Cell
Email*
Type of Organization*
- Healthcare Purchaser
- Healthcare Provider
- Health Plan
- Health Support Organization
- Affiliate
Organization Information (please state briefly the business function of your organization)*
Number of New Mexico employees*
For Employer Purchasers:
Do you self-insure?
- Yes
- No
If yes, approximately what percentage of your covered lives is through self-insurance:
Do you purchase fully insured products from health plans?
- Yes
- No
If yes, please list the health plans you currently contract with:
Approximate number of covered employees:
Approximate number of covered dependents:
Approximate number of covered retirees:
Approximate number of total covered lives:
For Healthcare Providers: Number of providers in New Mexico
For Hospitals: Number of Beds
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Email
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*Note: Membership dues are invoiced annually and are for 12 months. Dues must be paid within one month of being invoiced. No refund of annual dues is available if your organization chooses to leave the Coalition before the 12-month membership period ends.

New Mexico Coalition for Healthcare Value Membership Application

For Employer Purchasers:

New Mexico Coalition for Healthcare Value
PO Box 20146
Albuquerque, NM 87154

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