Name of Clinic/Organization
QUALIFYING INFORMATION
A. I attest that this clinic/charitable care organization is (please check all that apply):
A nonprofit organization with 501(c)3 tax-exempt status A program of a larger nonprofit organization Name of parent organization A start-up organization that plans to file for 501(c)3 nonprofit status An individual or business wishing to support the Washington Healthcare Access Alliance
B. I attest that this clinic/organization meets the criteria of a Free Clinic or Charitable Care Organization.
Free Clinic: a nonprofit organization that provides direct healthcare services at little of no cost to the underserved/indigent population of Washington through the use of volunteer health professionals, community volunteers, and partnerships with other healthcare providers.
Charitable Care Organization: a nonprofit organization that provides, coordinates or supports healthcare access for underserved/indigent communities.
Associate memberships are available for organizations that do not meet the criteria listed above and for individuals who wish to join the WHAA.
Annual Dues Free Clinic: $100 Charitable Care Organization: $100 Associate Organization: $500 Associate Individual: $50
Select Payment Method Pay with credit/debit card. Please send an invoice.
Open Since (YEAR)
This organization is not yet serving patients.
Mailing Address, Phone, Email, and Website
Services Provided
Acute Medical Chronic Medical Dental Case Management Vision Mental Health Care Coordination Other Other Services
Patients Served per Year
Patient Visits per Year
DESIGNATED REPRESENTATIVE INFORMATION
Please designate a representative with whom WHAA can communicate important updates and membership notifications.
Name
Title
Phone
Email
Submit
