WAMES - Wisconsin Association of Medical Equipment Services

Wames Membership Form

Company:

Name:

Title:

Email:

President/CEO:

Address:

City:

State:

Zip:

Phone:

Fax:

Are you a subsidiary or franchise of another company?
If yes, please provide the following information:

Parent Company
President/CEO:
Address:
City:
State:
Zip:
Phone:

Type of business please select

Company's top revenue producers in ranking order

DME PEN Rehabilitation Oxygen Disposables Other

Class of Membership

Regular - A sole proprietorship, partnership, firm or corporation currently engaged in the retail/wholesale, rental or distribution of any type of medical equipment, products, services, or suppliers for home use in the care and treatment of patients. All organizations who bill Part B for their Medicare patients qualify to be a Regular Member. A Regular Member shall have full voting rights.
Associate - A person, partnership, firm or corporation not otherwise qualified for regular membership that engages through manufacturing, wholesale or otherwise a business that supports or enhances a regular member's health care business.

Dues Classification
In accordance with the descriptions outlined above, our company is in the following category (please select one )

Dues:

Membership Category

$595

Regular Member, Net Revenue of less than $1,000,000

$795

Regular Member, Net Revenue between $1,000,000 - $3,000,000

$995

Regular Member, Net Revenue between $3,000,000 - $7,000,000

$1095

Regular Member, Net Revenue over $7,000,000

II Associate Membership

*$1,395.00

$1,395.00 by January 31st. or 1,495.00 after january 31st

Package B :
One year’s membership in WAMES
Current membership directory of all WAMES members
Receive quarterly newsletter, The Outlook
Listing in The Outlook Newsletter
Opportunity to advertise in The Outlook at the member rate
Opportunity to attend conferences and educational programs at the member rate
Opportunity to run for a Board Position
TWO booths at the Annual Conference (Value $700.00, $900.00 non-member)
FULL PAGE ad in WAMES newsletter (Value $165.00, non-member 225.00)
Sponsorship of ONE golf hole (Value $150.00, non-member 250.00)
Sponsorship of FOUR golfers at our Annual Golf Outing (Value approx. $280.00)
An Ad on the WAMES web site
MVP Recognition on promotional information for seminars and conferences

*$895.00

$895.00 By January 31st or $995.00 after January 31st

Package A:
One year’s membership in WAMES
Current membership directory of all WAMES members
Receive quarterly newsletter, The Outlook
Listing in The Outlook Newsletter
Opportunity to advertise in The Outlook at the member rate
Opportunity to attend conferences and educational programs at the member rate
Opportunity to run for a Board Position
And…Web page link
ONE booth at the Annual Conference (Value $350.00, $495.00 non-member)
HALF PAGE ad in WAMES newsletter (Value $95.00, non-member 150.00)
Sponsorship of ONE golf hole (Value $150.00, non-member 250.00)
Sponsorship of TWO golfers at our Annual Golf Outing (Value approx. $140.00)

*$595.00

$595.00 by January 31st or $695.00 after January 31st

Standard Membership
One year's membership in WAMES
Current membership directory of all WAMES members
Receive quarterly newsletter, The Outlook
Listing in the Outlook Newsletter
Opportunity to advertise in The Outlook at the member rate
Opportunity to attend conferences and educational programs at the member rate
Opportunity to run for a Board Position

Do you bill part B for Medicare patients?

Has your company ever been convicted of any health care crimes?

Has your company ever been convicted of a felony under Federal or State law?

Has any family and/or household member(s) of the applicant who has ownership or control interest in the enrolling business or entity? If yes, please supply the name of family/household member and relationship to applicant.

Name:

Relationship:

Check below if the applicant has ever had any of the following adverse legal actions imposed by the Medicare, Medicaid or any other federal agency program. For each item checked, include the date of the adverse legal action.

		Dates if applicable
Administrative Sanction(s):
Program Exclusion(s):
Suspension or Payment(s):
Civil Monetary penalty(s):
Assessment(s):
HealthCare Related Criminal fine(s):
Restitution Order(s):
Pending Civil judgment(s):
Judgment(s) pending under False Claims Act:
None of the above:

Does the applicant have any outstanding criminal fines?

Does the applicant have any outstanding Restitution orders?

Does the applicant, under any name or business identity, have any outstanding overpayments with Medicare, Medicaid or any other federal program?

If yes, under which federal program?

if yes, under what name?

Certification
I certify that the information submitted in this application is true, complete and correct to the best of my knowledge and belief and further agree to comply with the WAMES Code of Ethics and Federal, State and Local Regulations.

Signature_________________________________
Date_____________________________________

Any questions, please contact Ann Barrett, Executi ve Director of WAMES:
at abarrett@uniontel.net or 715/366-7500. Fax: 715/366-4501
WAMES, PO Box 389, Wild Rose, WI 54984 www.wames.org

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