(215) 676-7940

DVHCC Member Form Application

All applications for membership and renewal of membership are subject to approval by the DVHCC Board of Directors and contingent upon receipt of a check for Seven Hundred Fifty ($750.00) dollars representing the one-time initiation fee of Five Hundred ($500.00) dollars and the first year’s annual dues of Two Hundred Fifty ($250.00) dollars. Please make your check payable to the Delaware Valley Health Care Coalition, Inc.

By completing this application, you hereby represent that you have the legal authority to bind your organization; and hereby agree as follows:

  1. To adhere to the obligations of Members of the Delaware Valley Health Care Coalition, Inc. in conformance with the Articles of Incorporation, By-Laws, and their Amendments, as well as any and all Resolutions passed by the Board of Directors of the Coalition.
  2. To pay all applicable utilization fees as determined by the Delaware Valley Health Care Coalition Board of Directors as set forth in all vendor contracts that our organization becomes signatory to and receives such benefits of while continuing to maintain membership in the Coalition.
  3. Further, as a Member of this Coalition, our organization acknowledges and agrees that if our organization fails to maintain “good standing” membership in the Delaware Valley Health Care Coalition, Inc. and continues to receive any pricing, discounts, rebates and/or quality services set forth in any Umbrella contract and/or Member Agreement to which our organization is signatory, then the DVHCC has the right to charge our organization an “access fee” equivalent to the normal utilization fees owed under the vendor contract based upon our organizations’ past year’s utilization for so long as our organization continues to receive such Coalition-negotiated benefits.
  4. Further, it is the understanding of our organization that the Coalition has the right and obligation to collect any access fee or utilization fees either directly from the Vendor or Member should the Vendor fail to properly collect the utilization fees and remit the same to the Delaware Valley Health Care Coalition.
  5. As a Member of this Coalition, our organization acknowledges and agrees that in order to determine the vendor’s compliance with the terms of the contract and affiliated Member Fund agreements, the Coalition has the authority to acquire from all vendors certain de-identified, summary information and reports, provided that the information is consistent and in compliance with the provisions of the “Privacy Rule” (set forth in 45 CFR Part 164) of HIPAA.


    Contact Person

    Contact Person Name

    Contact Person’s Title

    Is Contact A Third-Party Administrator?

    If Yes, TPA Firm






    Cell/2nd Phone



    Employee Identification Number

    Fund Participants

    Active Members

    Active Members’ Dependents

    Retired Members

    Retired Members’ Dependents

    Total Participants


    Consultant/Actuarial Firm

    Medical Carrier

    Medical Carrier Name

    Insured Or Self-Insured?

    Medical Renewal Date

    Stop-Loss Provider

    Stop-Loss Renewal Date

    Typical Hourly Welfare Fund Contribution Rate (in Dollars)

    Retiree Medical Carrier

    Retiree Medical Carrier Name


    Insured Or Self-Insured?

    Medicare Eligible

    Insured Or Self-Insured?

    Pharmacy Benefit Manager

    Pharmacy Benefit Manager Name

    Insured Or Self-Insured?

    Pbm Renewal Date

    If You Cover Medicare-Eligible Participants, Are They Enrolled In Either RDS or EGWP Programs?




    Dental Carrier

    Dental Carrier Name

    Insured Or Self-Insured?

    Dental Renewal Date

    Life Insurance Carrier

    Life Insurance Carrier Name

    Insured Or Self-Insured?

    Life Renewal Date

    Vision Carrier

    Vision Carrier Name

    Insured Or Self-Insured?

    Vision Renewal Date

    Fiduciary Insurance Carrier

    Fiduciary Insurance Carrier Name

    Fiduciary Insurance Renewal Date

    Future Issues You Would Like The Dvhcc To Address

    Notes/Additional Information