2019 Provider Member Form

Provider Member Information

Organization Name
City State Zip
Work Phone Fax
Toll Free
Name of Central Office (Corporate) If Applicable:

Key Contact

First Name
Last Name

Program Service Revenue

Program service revenue activities are "primarily those that form the basis for an organization's exemption from tax," according to the IRS. Program service revenue is reported on IRS Form 990 of the most recently completed fiscal year. If your organization does not file Form 990 with the IRS, program service revenue may be identified in an organization's most recent Audited Financial Statement, Medicaid cost report or Profit and Loss statement.
NOTE: Hospice Providers - Please report Program service revenue minus room and board.
Your Program Service Revenue (PSR) for the most recent completed fiscal year:
Indicate Year of PSR:

Membership Type

Check your PRIMARY member type.
County Home
Home & Community Based Services (HCBS)
Home Care
Life Plan Community (CCRC)
Nursing Facility (NF)
Palliative Care Only
Residential Care Facility
Skilled Nursing Facility (SNF)
Other (Specify):
Are you Medicare certified?
Are you Medicaid certified?

Services Offered

Please select all services offered by your organization:
This information is used in our Find a Provider search for consumers and in our advocacy efforts.
Adult Day
     Adult Day Medical
     Adult Day Social
Affordable Housing
     HUD/Subsidized Housing
     Tax Credit-Funded Housing
Assisted Living
     Assisted Living Waiver
Allow Pets
Chore Services
Dementia Care/Memory Support
Developmental/Intellectual Disability Services
Enhanced Community Living
Emergency Response
Geriatric Clinic
Home Health Care
Hospice Care
Independent Living (Market Rate)
Meals on Wheels
Other HCBS(Specify):
Other Special Service(Specify):
PACE Program
Palliative Care
Personal Care
Private Duty nursing
Respite Care
Service Coordination
Skilled Nursing
Short-Term Rehab/Sub-Acute Care
   - denotes required fields

Our national partner, LeadingAge, is an association of 6,000 not-for-profit organizations dedicated to expanding the world of possibilities for aging. Together, we advance policies, promote practices and conduct research that support, enable and empower people to live fully as they age.