Follow the steps to complete your application online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the primary contact section. Here, enter the company name, website, specialty, phone number, address, city, and state. Ensure that all information provided is accurate and up-to-date.
3. Next, move to the additional employee emails section. You can enter up to two names along with their corresponding email addresses. This is important for communication purposes.
4. In the additional information section, indicate whether the facility is licensed by the NJ Department of Health. Provide details about the type of business and the percentages for physician ownership, management company, and hospital ownership.
5. Fill in the medical director or facility owner section with their name and contact information.
6. Choose your preferred payment type. If paying by credit card, fill in the credit card information including the type, number, expiration date, billing address, name on the card, and zip code.
7. In the 'who referred you' section, provide the relevant email address of the person who referred you, if applicable.
8. Indicate whether the facility is Medicare-certified and provide the number of rooms in the facility.
9. You may also list any facility accreditation and indicate if you would like to request an invoice.
10. Finally, review all provided information for accuracy and completeness. Then, authorize the verification of the information by signing and dating the application as the applicant.
11. After completing the application, you can save changes, download, print, or share the form as needed.

Complete your NJ AASC Facility Membership Application online today!