2012 Home Care Membership Application-Main Site

Please complete the information below. If your agency has Alternative Delivery Sites, you must also complete that application for each site, found on the Membership page.
Agency Information:
Agency
Address
City State Zip
Phone Toll Free Phone
Fax
Website
County (Primary Location)
Name of Person Completing Application
Executive Director:
Name
Email
  Primary Contact is Executive Director.
Primary Contact:
Name
Title
Email
Clinical Director (if different from above)
Name
Email
Accounts Payable Representative:
Name
Email
Case Manager:
Name
Email
Marketing/Public Relations Representative:
Name
Email
Total Number of Patients Served in most recent year of full data:
Medicare Federal ID#
National Provider ID#
What percentage of your business is:
Medicare Medicaid
Waiver Private Insurance
Charity Passport/Choices
MR/DD I/O Waiver
Other
Disciplines (check all that apply):
  SN OT Aide
  PT SLP MSW
Services Provided (check all that apply):
  Private Duty RN Personal Care Services
  Indep. Living Aide Maternal/Child Health
  Emerg. Response Chore Services
  Hospice Pediatrics
  Transportation Respite
Are you Accredited?
 If Yes, which accreditation do you have?
 
 Date of Last Visit: ?
Have You Received "Deemed Status Accreditation"?
Please select all counties that your organization serves:
This information is used in our Membership Directory
Adams Allen Ashland Ashtabula Athens
Auglaize Belmont Brown Butler Carroll
Champaign Clark Clermont Clinton Columbiana
Coshocton Crawford Cuyahoga Darke Defiance
Delaware Erie Fairfield Fayette Franklin
Fulton Gallia Geauga Greene Guernsey
Hamilton Hancock Hardin Harrison Henry
Highland Hocking Holmes Huron Jackson
Jefferson Knox Lake Lawrence Licking
Logan Lorain Lucas Madison Mahoning
Marion Medina Meigs Mercer Miami
Monroe Montgomery Morgan Morrow Muskingum
Noble Ottawa Paulding Perry Pickaway
Pike Portage Preble Putnam Richland
Ross Sandusky Scioto Seneca Shelby
Stark Summit Trumbull Tuscarawas Union
Van Wert Vinton Warren Washington Wayne
Williams Wood Wyandot
2012 Dues Calculation: No Increase in Dues for 2012!
Please use your 2010 Gross Revenue information in order to determine your dues. Gross revenue includes all revenue generated from in-home care ONLY. Exclude hospice and/or other non-related business costs. Hospice organization membership is calculated separately.
Your dues are based on the following table:
Revenue : Dues
Up to $999,999 : $500
$1M to $6.5M : (Revenue x .00075)
>$6.5M to $10M : $5,000
>$10M to $15M : $5,300
>$15M to $25M : $5,700
>$25M to $35M : $6,200
>$35M : $7,000
Once you have determined your gross revenue, please enter it here:
Membership Discount Program
In an effort to assist programs with rising costs we are facing in today's economy, Midwest Care Alliance is pleased to offer a discount program of 10% off of total dues if both home care and hospice join Midwest Care Alliance and dues are paid in full.
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