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Organization *
Phone *
Website
Membership Type * Please choose one Newly Licensed Membership Pending Licensure Membership Single License Membership (Bronze-Silver-Gold-Platinum) Multi-Agency License Membership (Bronze-Silver-Gold-Platinum) Individual Membership Sponsor Membership
Provider Agency Licensure Type * Please choose one HHAS (Home Health/Skilled) HHAO (Home Health Aide Only) Hospice PASA (Personal Assistance Service Agency Allied (Non Home Care or Hospice Provider)
Bronze Single License: Annual Revenue less than $1 million Annual (pay in full by January 15th) - $ 600.00 Annual (pay in full by January 15th) - $ 600.00 Annual (pay in full after January 15th) - $ 750.00
Silver Single License: Annual Revenue $1-3 million Annual (pay in full by January 15th) - $ 1,100.00 Annual (pay in full by January 15th) - $ 1,100.00 Annual (pay in full after January 15th) - $ 1,250.00
Gold Single License: Annual Revenue $3-6 million Annual (pay in full by January 15th) - $ 1,600.00 Annual (pay in full by January 15th) - $ 1,600.00 Annual (pay in full after January 15th) - $ 1,750.00
Platinum Single License: Annual Revenue greater than $6 million Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full after January 15th) - $ 2,250.00
Bronze Multi License: Annual Revenue less than $1 million Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full after January 15th) - $ 2,250.00
Silver Multi License: Annual Revenue $1-3 million Annual (pay in full by January 15th) - $ 1,100.00 Annual (pay in full by January 15th) - $ 1,100.00 Annual (pay in full after January 15th) - $ 1,250.00
Gold Multi License: Annual Revenue $3-6 million Annual (pay in full by January 15th) - $ 1,600.00 Annual (pay in full by January 15th) - $ 1,600.00 Annual (pay in full after January 15th) - $ 1,750.00
Platinum Multi License: Annual Revenue greater than $6 million Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full by January 15th) - $ 2,100.00 Annual (pay in full after January 15th) - $ 2,250.00
Enter the number of additional licenses (Excluding your primary membership license) *
Agency Name *
Email *
Phone *
Alternate Representative Email
Alternate Representative Phone
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