Louisiana Ambulatory Surgery Association

LOUISIANA AMBULATORY SURGERY CENTER ASSOCIATION

2018 MEMBERSHIP APPLICATION

Applicant Name: ______

Applicant’s ASC: ______

Mailing Address: ______

Address: ______City: State: Zip Code:

Telephone #: ______Fax #: ______

List Contact Person(s) – (maximum of two) – to whom LASCA information should be sent (Newsletters, special notices)

(1) ______Name Title

______e-mail address

(2) ______Name Title

______e-mail address

Note: LASCA has an agreement with LAMMICO that provides for the reimbursement of membership dues paid to LASCA if your ASC is an insured of LAMMICO. Each month, LASCA provides an updated membership roster to LAMMICO and they reimburse ASCs who have paid their membership dues to the Louisiana Ambulatory Surgery Center Association.

I/we hereby apply for membership in the Louisiana Ambulatory Surgery Center Association (LASCA) and agree to abide by such Bylaws and/or rules of the Association. The information herein is true and to the best of my/our knowledge.

______Signature Print Name Date

Annual Dues: $500

You can now renew online at www.la-asa.org For more information call (225) 933-5435

Please make your check payable to LASCA and mail along with the completed membership application to LASCA P.O. BOX 14940 Baton Rouge, LA 70898-4940 Louisiana Ambulatory Surgery Association PO BOX 14940 Baton Rouge, LA 70898-4940 (225) 326-3180 Office (225) 208-1932 Fax www.la-asa.org

Louisiana Ambulatory Surgery Center Association & LAMMICO Partnership

LASCA is pleased to recognize LAMMICO as their preferred provider of medical professional liability insurance.

Superior reputation protection, risk management education and customer service at the greatest value to local surgical centers.

Thanks to a partnership between LASCA and LAMMICO, any LASCA member who is insured by LAMMICO is eligible for a 5% premium discount applied to member facility medical professional liability premiums when they attend an annual LAMMICO risk management lecture like the upcoming 2018 Annual Meeting at the West Baton Rouge Conference Center. LAMMICO even reimburses LASCA membership dues after you pay LASCA directly. Comprehensive coverage and extensive medical professional liability insurance customer service are now available to ambulatory surgery facilities through LAMMICO.

Each year LAMMICO develops a tailor-made Risk Management program for LASCA members that are given at the LASCA annual meeting. Members who attend this special Risk Management program are eligible for an additional 5 percent credit off their LAMMICO basic limits premium.

In addition LAMMICO reimburses the LASCA dues for LAMMICO insureds who are or who wish to become LASCA members.

When applying for coverage, please note on your application that you are a member of LASCA. For more information about this program, please call one of our Marketing Representatives serving the following area codes:

LAMMICO’s Marketing Representatives:  Kendall Ankesheiln, 504-841-5285, [email protected]  Kylie Fontenot, 504-841-2701, [email protected]  Stan Gavin, 225-906-2258, [email protected]  Tara McGinty, 318-219-4924, [email protected]  Carly Thames, 225-906-2062, [email protected]

To learn more about LAMMICO, visit www.lammico.com .

For more information about becoming a LASCA member, please contact Sarah Heath, LASCA Membership Director at [email protected] or 225-326-3180.

Louisiana Ambulatory Surgery Center Association P.O. BOX 14940 Baton Rouge, LA 70898-4940 (225) 326-3180 (Office) (225) 208-1932 (Fax) www.la-asa.org

LASCA Code of Ethics (Must be signed by each LASCA Member according to LASCA Bylaws)

 Members shall direct their activities to the mission, goals and objectives of LASCA, which are to elevate through education the competence, standards and knowledge of all members.

 Members shall not misuse information disseminated in LASCA publications, meetings, workshops, seminars or other LASCA functions. Misuse of information includes representing LASCA information to other persons as having been authored or originated from any person or organization other than LASCA.

 Members who also sell products or services shall not utilize information obtained at LASCA functions such as meetings, workshops or seminars for their personal financial gain, including the solicitation of such products or services at any time during LASCA functions, except when acting in the capacity of exhibitor or in the normal course of membership.

 Members shall not disparage the work or conduct of other members, but shall report unprofessional and/or unethical conduct to the Board of Directors.

 Members shall conduct themselves in a professional manner, maintaining a high personal standard of professional integrity and ethics.

Date: ______

Printed Name: ______

Title: ______

ASC: ______

Signature: ______