`SouthEast Texas Regional Advisory Council`

`S.E.T.R.A.C. ( TSA Q )`

* Join/Update Information

* Organization / Company Name

* Organization Type:

* Name of Contact

* Title of Contact

* Mailing Address Line 1:

Mailing Address Line 2:

* City State Zip:

* Phone Number(s):

* Email Address:

Fax Number:

`Participation Requirements`

Hospital Requirements: (1) Attend a minimum of 2 Quarterly Meetings, (2) Pay Annual Dues

EMS Requirements: (1) Attend a minimum of 2 Quarterly Meetings, (2) Attend 50% of a SETRAC Committee's Meetings, (3) Attend 50% of the SETRAC EMS/SQI Committee Meetings, (4) Pay Annual Dues

`Annual Dues`

* Dues ( Fiscal Year: Sept 1 - Aug 31 ):
EMS Agency
Large (>7,500 transports annually)
Medium (2,500 - 7,500 transports annually)
Small (<2,500 transports annually)

Hospital Fee Structure
General Acute Care Hospital = $750
Cardiac, Stroke, Level I/II = $350 each additional level/specialty
Level III Trauma = $225
Level IV Trauma = $150
LTAC, Rehab, Other = $500
(Maximum Basic Fee = $1,800)

EMS Agency = Large $850

EMS Agency = Medium $500

EMS Agency = Small $250

Hospital = Contact SETRAC Office for dues invoice.

Dues already paid this fiscal year

Please print a copy of this form ( by right clicking the mouse & select print ) and mail along with annual dues payment to:

SETRAC
1111 North Loop West, Ste 160
Houston TX 77008

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