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Instructions

Please complete this application in its entirety. 

The HCBS provider membership is open to businesses who provide person-centered care in the home and community. These programs help individuals who need assistance with everyday activities. 

Eligible services for this membership include:  non-medical home care, durable medical equipment, behavioral health, therapy services, transportation, and senior centers. 

            

Select Your Option(s)

Non-Medical Home Care membership is open to businesses who provide person-centered care in the home and community. These programs help individuals who need assistance with everyday activities. Eligible services for this membership include:  durable medical equipment, behavioral health, therapy services, transportation, and senior centers.This is a non-voting membership.

            

Private Pay Private Duty Membership is open to businesses who provide person-centered care in the home and community. These programs help individuals who need assistance with everyday activities. Eligible services for this membership include:  durable medical equipment, behavioral health, therapy services, transportation, and senior centers. This is a non-voting membership.

Enter Contact Information
Please select a valid membership option and fee item if exist
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