Become a Member

To apply for a new Primary Care Provider membership of IPHCA, please complete the following application form.
For Affiliate, Individual and Training applications, click here.
Applicant name*
Organization*
Mailing address*
(corporate office / official business location)

Street Address Address Line 2 City State ZIP
Telephone*
Fax
Contact mobile
Contact email*
Website URL*
Date organization / center ﬁrst opened*
Date ﬁrst received State funding
Date ﬁrst received Federal funding

Application summary

You have indicated the following choices:
at the membership level
Payment schedule*
IPHCA membership fees paid in instalments will be invoiced on dates shown. Invoices not paid within 14 business days of date on invoices will result in loss of member privileges until fees are paid in full.
- Full Annual Payment
  (Payable immediately)
- Two semi-annual payments
  (Payable immediately and on October 1)
- Four quarterly payments
  (1st payment due immediately, remainders will be invoiced on July 1, October 1 and January 1 of the following year)
Documents required
Please supply copies of required documents as pdf or jpeg files.
Most recent completed Fiscal Year-End Financial Statement*
Accepted file types: jpg, jpeg, pdf, Max. file size: 512 MB.
Current and complete listing of Clinical, Mental Health, and Dental Providers*
Please list by position; Full Time Equivalent (FTE) as of 1/1/21. Please include any current vacancies
Accepted file types: jpg, jpeg, pdf, Max. file size: 512 MB.
Copy of Organization Bylaws*
Accepted file types: jpg, jpeg, pdf, Max. file size: 512 MB.
List of Services Provided*
Accepted file types: jpg, jpeg, pdf, Max. file size: 512 MB.
Current Copy of Sliding or Reduced Fee Scale*
Accepted file types: jpg, jpeg, pdf, Max. file size: 512 MB.
Uploading issue
If you experience difficulty providing documents online, please check this box and our team will contact you to assist.
Please note
- Aggregate data gathered from the required documents will be used for lobbying and education efforts for key stakeholders.
- Individual CHC information obtained from the required documents will not be shared without permission from the individual health center.
- IPHCA’s membership list may not be sold or shared with any non-member entity or non-member individual.
- Information gathered through any participation or interactions as an IPHCA member must be treated as confidential and considered proprietary in nature.
By clicking Submit below, you indicate your support for the work of the Indiana Primary Health Care Association and a desire to become a supporting member.

Contact our membership team with any questions.

New Primary Care Provider Application

Step 1 of 3 - Your Details

Application summary

Please note

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