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 2012 through May 2013.

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 155
Alexandria, MN 56308
HUG Tax Payer ID: 02-0433794

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

If you have any questions, please contact me at jqueen@connecticare.com.

Thank you,
Jerry Queen
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 Bruce Wegner at 320-335-5231 or by email at Bruce.Wegner@primewest.org.

Return to top