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YOUR CART
Application
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Organization Information (to be displayed online)
Organization Name
Address 1
Address 2
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State
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IA
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MB
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NS
NT
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ON
PE
QC
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YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
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Main Contact
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First Name
Last Name
Address 1
Address 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Title
Phone
Email
Membership Investment
Membership Type
Select one...
Licensed Home Health Agencies
Hospice and Palliative Care Agencies
Adult Day Health Centers
Non-Medical In-Home Services Organizations (Personal Care Services)
Organizational/Affiliate Membership
Primary Directory Category
None
Accreditation
Accreditation - ACHC
Accreditation - CHAP
Accreditation - JCAHO
Behavioral Health
Bereavement/ Grief Counseling
Case Management
CHHA Hourly
CHHA Live-in
Chronic Care Mngt
Classification-Corporation
Classification-Hospital Base
Classification-Individual/Sole Proprietor
Classification-LLC
Classification-Public Health Dept.
Companions /Sitters
Dementia Care
Emergency Response Systems
EPSDT Special Services- OT
EPSDT Special Services- PT
EPSDT Special Services- ST
Geriatric Care Management
HC Waiver Case Management
HC Waiver Services Provider
Home Health Aides
Home Infusion / Intravenous Therapy
Home Medical Equipment
Hospice
Insurance Accepted/Payer - Commerical Insurance
Insurance Accepted/Payer - Medicaid FFS
Insurance Accepted/Payer -Medicaid Managed Care
Insurance Accepted/Payer-Aetna
Insurance Accepted/Payer-Anthem
Insurance Accepted/Payer-Humana
Insurance Accepted/Payer-Medicare
Insurance Accepted/Payer-PassPort
Insurance Accepted/Payer-Private Pay
Insurance Accepted/Payer-VA
Insurance Accepted/Payer-Wellcare
Insurance Accepted/Payer-Workers Comp
License Type- Adult Day
License Type- Affiliate
License Type- Home Health
License Type- Hospice
License Type- Infusion
License Type- Networking
License Type- Non-Medical In-Home Services
License Type- Organizational
License Type- Palliative Care
License Type- Personal Care Services
License Type- Personal Service Agency
License Type- Private Duty Nursing
License Type: Home Health
Licensed Practical Nursing
Maternal Health
Medical Social Services
Medication Management
Member Of - HCAOA
Member Of - KAPP
Member Of - KPTA
Member Of - KRHA
Member Of - Leading Age KY
Member Of - NAHC
Member Of - NHPCO
Member Of - VNAA
Mobile Meals
Nursing
Occupational Therapy
Palliative Care
Pediatric Care
Pediatric Hospice
Personal Care Services
Physical Therapy
Private Duty Nursing
Psychiatric Nursing
Registered Dietitian
Respite Care
Shift Nursing
Skilled Nursing
Speech Therapy
Supply only patients
Telehealth Monitoring
Training
Transporation
Ventilator Care
Waiver Services
Additional Directory Categories
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none
Visits Per Year
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1-6000
6001-12000
12001-18000
18001-24000
24001-30000
30001-36000
36001-50000
50001-100000
100001-Over
Annual Membership Investment
Total
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Additional Items
Additional Categories Cost
One-Time Application Fee
Tax
Number of Full Time Employees
Number of Part Time Employees
Number of Rooms
Number of Seats
Number of Associates
Number of Locations
Millions in Assets
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
Additional Categories
Number Of Additional Categories
Additional Categories Cost
Additional Item 1 Cost
Additional Item 2 Cost
Additional Item 3 Cost
Additional Item 4 Cost
Additional Item 5 Cost
Additional Item 6 Cost
Additional Item 7 Cost
Additional Item 8 Cost
Additional Item 9 Cost
Additional Item 10 Cost
Annual Dues (charged to card)
Revenue Item
Tax (charged to card)
Fee (charged to card)
Temp Value For DropDown 1
Membership Type
Additional Item 1
Additional Item 2
Additional Item 3
Additional Item 4
Additional Item 5
Additional Item 6
Additional Item 7
Additional Item 8
Additional Item 9
Additional Item 10
Payment Type
Credit Card
Check
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Credit Card Information
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Credit Card Type
Mastercard
Visa
Discover
Amex
Credit Card Number
Name on Card
Security Code
Valid Through
01
02
03
04
05
06
07
08
09
10
11
12
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
Address
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
AG
BN
BS
CH
CL
CM
CP
DF
DU
GR
GT
JA
MC
MR
MX
NA
OA
PU
QE
QR
SI
SL
SO
TB
TL
TM
VE
YU
ZA
Outside US
Outside Canada
Outside Mexico
Zip
Phone
Credit Card Email Address
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