Please complete this application for membership in its entirety. 

A primary provider is a business or corporation/entity that provides direct health care services in Ohio under common ownership, control, or board direction, including locations, sub-units, and programs providing in-home patient services, hospice, and palliative care.

Please select the option below for your agency's gross revenue across all locations for home and community-based services.

Annual dues for all provider/voting members are based on gross revenue for the previous fiscal year generated in from all locations and all patient revenue payers related to home and community-based services. 

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Please select a valid membership option and fee item if exist
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