CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 6)

 

Welcome to the CAHSAH online membership application. The next several pages will allow you to apply for membership to CAHSAH and either pay online with a credit card or check by mail. If you choose to pay by check, this process will create an invoice which can be included with your check. If you choose to pay by credit card, you will be directed to a secure credit card page which will ask for your credit card information. Fields marked with an * are required fields. Thank you for your continued support of CAHSAH.
 
*Application Type:    Renewing Member      New Member  
 
*Agency Name: 
*Mailing Address:  *City: 
*State:  *Zip Code: 
*Telephone:  Fax Number: 
E-Mail:  Web Address: 
You must enter at least one license number below:
*Department of Social Services, Home Care Services Bureau License #: 
*Department of Public Health Home Health Agency or Hospice License #: 
Has your agency or any other agency with which you have been affiliated ever had their CAHSAH membership or CAHSAH Home Care Aide Organization Certificate revoked or denied?   Yes     No
If Yes, please explain:
Conditions of Participation
  I Agree      I Do Not Agree