Join the Membership - Kentuckiana Health Collaborative

The KHC works through broad collaboration to improve the health status and healthcare delivery system in Greater Louisville. All members are listed on the KHC letterhead and website. Follow the below steps for joining the KHC.

You can join the KHC by downloading the forms or filling them out online below.

Complete the KHC Membership Form and submit your membership fee (fee schedule is located on the form).
Complete a Conflict of Interest Disclosure Form. It is required for voting and alternate representatives for your organization, but not for general members you choose for the KHC communication list.
Members should submit their approved logo with any specifications required for publication to the KHC Office. Logos are used on our letterhead, our website, event signage, and other publications to promote the KHC.

KHC Member Benefits

Contact the KHC office with any questions at 502-238-3603.

Join or Renew Now

Complete this form to join the KHC along with a conflict of interest policy annually. All members are listed on the KHC letterhead and website. Members should submit their approved logo with any specifications required for publication to Jenny Goins, President and CEO, at jgoins@khcollaborative.org. Note that you may add any conference sponsorships to your renewal with the Paypal payment option. To do so, put the combined amount into the dues amount box. For sponsorship levels and prices, download the sponsorship prospectus at www.KHCollaborative.org/conference.

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	# of Employees	Annual Dues
Healthcare Purchaser and Employer Members	<500	$375
	500 - 1,999	$750
	2,000 - 4,999	$1,875
	≥5,000	$3,750
Plans, Health Systems, and Hospitals		$10,000
Pharmaceutical		$5,000
Healthcare Point Solutions		$5,000
Consultants		$5,000
Health Services Providers, Managed Medicaid, etc.	<500	$1,000
	>500	$2,500
Government, Public Health Partners, and Non-Profit Friends Representing the Community	<500	$250
	500	$500

Payment options*

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Please fill in the dues amount:

Payment Method

Business or Organization*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact for Renewal*

First Last

Renewal Contact Email Address*

Voting Member Name*

Title*

Voting Member Email*

Alt. Voting Member Name

Title

Alt. Voting Member Email

Conflict of Interest Disclosure Form

Name*

Organization*

Member Type*

Member

Board of Director

Committee Member

KHC Vendor

The purpose of the conflict of interest policy is to protect the Kentuckiana Health Collaborative's interest when contemplating entering into a transaction or arrangement that might benefit the interest of a Director, Officer, or Member of the Collaborative. This policy is intended to supplement but not replace applicable state and federal laws governing conflict of interest applicable to nonprofit and charitable organizations.

Terms and Definitions. The term "interest" shall include personal interest, interest as Director, Officer, Member, stockholder, shareholder, partner, manager, trustee, or beneficiary of any concern and having an immediate family member who holds such an interest in any concern. The term "concern" shall mean any corporation, association, trust, partnership, limited liability entity, firm, person, or other entity other than the Collaborative.

Disclosure, abstention, and rationale. No Director, Officer, or Member of the Collaborative shall be disqualified from holding any office in the Collaborative by reason of any interest in any concern; nor shall any Director, Officer, or Member be disqualified from dealing, either as vendor, purchaser or otherwise, or contracting or entering into any other transaction with the Collaborative or with any entity of which the Collaborative is an affiliate; nor shall any transaction of the Collaborative be voidable by reason of the fact that any Director, Officer, or Member of the Collaborative has an interest in the concern with which such transaction is entered into, provided that:

The interest of such Officer, Director, or Member is fully disclosed to the Board
Such transaction is duly approved by the Board not so interested or connected as being in the best interests of the Collaborative
Payments to the interested Officer, Director, or Member are reasonable and do not exceed fair market value
No interested Officer, Director, or Member may vote or lobby on the matter or be present when the matter is debated when the matter concerns only the particular entity or individual in which they have an interest or concerns a small group of entities or individuals that includes such a particular entity or individual.

Unless noted above, nothing prevents any Officer, Director, or Member of the Collaborative from full participation in discussion and debate about community needs, priorities, projects, and funds. After disclosing of an interest, the KHC Board will determine if a conflict of interest exists.

Conflict of Interest*

I have no potential conflict of interest to report

I have a financial interest, directly or indirectly, through business, investment, or family:

An ownership or investment interest in an entity with which the KHC has a transaction or arrangement,
A compensation arrangement with the organization or with an entity or individual with which the KHC has a transaction or arrangement, or
A potential ownership or investment interest in, or compensation arrangement with, any entity or individual with which the KHC is negotiating a transaction or arrangement.

Note: A financial interest is not necessarily a conflict of interest.

I hereby certify that the information set forth above is true and complete to the best of my knowledge. I have reviewed, and agree to abide by, the Kentuckiana Health Collaborative Conflict of Interest Policy.

Signature*

Date*

Join or Renew Now

Conflict of Interest Disclosure Form

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