Healthcare Users Group Membership Form

Member Application

Thank you for your interest in joining the Healthcare Users Group!

HUG is an independently operated user group. Annual dues are assessed on a per Company basis and offer voting privileges at our annual meeting. Annual dues are $250.00 per company per year. Only one payment is required per company but you may have several contacts. This year’s annual dues are good from June 2016 through May 2017.

Upon submission of this application, your membership will be updated once payment is received. Payment should be sent to:

HealthCare Users Group Inc.
PO Box 2461
North Canton, Ohio 44720

Please make checks payable to: Healthcare Users Group, Inc.

If you have any questions, please contact me at kinkeadd@summacare.com.

Thank you,
Denny Kinkead
HUG President

Membership Application Form

*Indicates a required field
1. Company Name:*
Company Mailing Address:*
Street:*
City:*
State:*     Zip:* 
2. Primary Contact:*
Salutation: First Name:* Last Name:*
Title:
Telephone:*
E-Mail:*
3. Product User:*
4. Type(s) of products offered by your company (check all that apply):
Commercial HMO
Medicaid
Medicare
Commercial PPO/POS
TPA
Self-Funded
Other
5. Please list the individuals in your organization who should receive future mailings and e-mails.
  Individual Name Position Phone E-Mail
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

To complete your registration, please enter the number verification code in the box below.
  *

Why do we do this? To ensure that you are a real human applying for HUG Membership. If you have any questions, please contact Michele Lang at 918-594-5295 x6326 or by email at michelle@ccok.com.

 

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