CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 5)

Welcome to the CAHSAH online membership application. The next several pages will allow you to apply for membership to CAHSAH by submitting your company information. You may choose to 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. Thank you for your continued support of CAHSAH.
Application Type: New Member Renewing Member

Agency Name:
Mailing Address:		City:
State:		Zip Code:
Telephone:		E-Mail:
Web Address (opt):

How many branches / additional licensed locations do you have (if none, please enter 0)?
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 1. Provider Membership in CAHSAH is open to direct providers of health and supportive services and products in the home. 2. Adherence to CAHSAH Code of Ethics. 3. Membership benefits begin with receipt of payment and continue for one year. Only employees of the member entity may utilize member benefits. 4. Dues are based on the number of licenses your agency holds and the number of branches/additional licensed locations serving your patients and clients. 5. Membership dues, set up fees and voluntary contributions are non-refundable. 6. Dues payments to CAHSAH are not deductible as a charitable contribution for federal income tax purposes. However, dues payments may be deductible as an ordinary and necessary business expense, subject to an exclusion for lobbying activity. Because a portion of your dues is used for lobbying by CAHSAH, 14% of your dues is not deductible for income tax purposes. I, as CEO, CFO or Executive Management, have read, understand and agree to abide by the Conditions of Participation. I further certify that I have accurately represented my agency's information.
I Agree I Do Not Agree

Credit Card Information
Please enter your credit card billing information below. If your billing address is different than your company mailing address please make changes below. You will not be asked for the credit card number or expiration date until you have gone to the secure payment site.
First Name:		Last Name:
Billing Address
City
State		Zip

CAHSAH Provider Membership Application - Basic Organization Information (Page 1 of 5)

Credit Card Information