Facility Membership Renewal

Facility Information

Fields marked with* are required.

Facility Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Facility Staff

Please enter the following information for your Account Manager.

The Account Manager manages all administrative aspects of the organization's account including updating the organization's demographic information, contact information, and staff roster. Additionally, the Account Manager acts as the billing contact for the organization. This person will receive an emailed confirmation of this submitted renewal.

Account Manager*

Prefix

First Name

Last Name

Account Manager's Credential(s) (e.g., MD, BSN, RN)

Account Manager's Title*

Account Manager's Primary Job Function*

Account Manager's Email*

Please enter the following information for the person completing this form.

Person completing this form is the same as Account Manager

Your Name*

Prefix

First Name

Last Name

Your Credential(s) (e.g., MD, BSN, RN)

Your Title*

Your Primary Job Function*

Your Email*

As a facility member, any employee of your ASC can access members-only content on the website, purchase publications and attend in-person and virtual educational events at the discounted member rate. To enroll staff, please complete the ASCA Contact Information Form.

Membership Package

Please enter the following information to calculate your 2024 membership dues payment.

Dues are calculated using the previous year's number of patient visits multiplied by a rate of $0.68/patient visit, with a minimum of $649 and a maximum of $3,375.

Number of Patient Visits in 2023 (or last 12 months)*

Your 2024 Dues ($0.68 x number of patient visits in 2023)* $

Dues Minimum: $649; Dues Maximum: $3,375

Your 2024 Dues* $

Dues Minimum: $649; Dues Maximum: $3,375

Your 2024 Dues* $

Dues Minimum: $649; Dues Maximum: $3,375

Terms and Conditions

ASCA resources are for your personal and noncommercial use. Members are responsible for maintaining the confidentiality of their passwords, and are not to share their user IDs or passwords with any third parties. You may not copy, replicate, modify, distribute, display, perform, create derivative works from, transfer or sell any information, software, products or services obtained from ascassociation.org in any medium or format, including, without limitation, human-readable, machine-readable, printed, visible, audible, electronic, by email forwarding, TV, satellite, digital transmission, scanned or website recycled, except where expressly noted that the material is available for such purpose.

Agree to Terms*

I have read and agree to the terms and conditions outlined above.

Dues payments to ASCA are not tax deductible as charitable contributions for federal income tax purposes. However, they may be deductible as ordinary and necessary business expenses subject to restrictions imposed as a result of ASCA’s lobbying activities. ASCA estimates that the nondeductible portion of your 2024 dues—the portion that is allocatable to lobbying—is 15%.

Payment Information

Total Due* $

Total Due $

Total Due* $

Total Due $

Total Due* $

How would you like to pay?*

Name on Credit Card*

Credit Card Number*

Card Verification Code

Expiration Date*

Name on Check*

Check Number

Account Number*

Routing Number*

Where you would like the receipt emailed?*

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