Georgia Association of Community Care Providers
Membership Application

Make checks payable to GACCP and mail to:
P.O. Box 3364
Gainesville, GA 30503
Or, call us at 678/943-2617 to pay by credit card.
please note on your check that your application was submitted on-line
PAYMENTS DUE BY JANUARY 1ST OF EACH CALENDAR YEAR

Please fill this form out completely.  Fields marked with an * are required.

I. Membership
* Type: Provider (Agency) Associate-Individual Associate-Organization
Please verify the records below as this information will be listed on your voters information.
* Company Name:
* Name of Contact Person: (title) Mr. Mrs. Ms. Dr. (name)
* Mailing Street Address:
* City: * State: * Zip Code:
Site Location (if different):
City: State: Zip Code:
* Phone Number: Fax Number: 800#:
* Designated Voter:
* E-Mail: Web Address:
* (Required for Providers only) Licensed Services: Nursing Personal Support Companion/Sitter
* (Required for Providers only) Programs in which your company participates: (check all that apply)
ALS (Alternative Living Services)
HDS (Health Day Services)
HDM (Home Delivered Meals)
ADH (Adult Day Health)
PSS (Personal Support Services)
PSSX (Personal Support Services Extended)
SOURCE (Service Option Using Resources in a Community Environment)
ICWP (Independent Care Waiver Program)
PHCP (Private Home Care Provider)
ERS (Emergency Response System)
CCSP (Community Care Service Provider)
MRDD (Mental Retardation/Developmental Disabilities)
Pediatrics
ORC (Out-of-Home Respite Care)
SKSPHCP (Skilled Nursing Services by Private Home Care Provider)
II. Dues: The dues structure is based on the honor system. The tier structure is based on projected annual revenue and not projected billing. We want to encourage you to choose the highest category your agency can support.
* Provider Membership:
Tier 1:
 Up to $60,000
$150.00
Tier 2:
 $60,000 to $150,000
$300.00
Voluntary PAC Donation
$25.00
Voluntary PAC Donation
$50.00
Total Tier 1
Total Tier 2
 
 
     
Tier 3:
 $150,000 to $300,000
$400.00
Tier 4:
 Over $300,000
$550.00
Voluntary PAC Donation
$75.00
Voluntary PAC Donation
$100.00
Total Tier 3
Total Tier 4
Associate Membership (for those who are not Providers)
Individual
$100.00
Voluntary PAC Donation
$25.00
Total for Individual
 
Organization
$100.00
Voluntary PAC Donation
$25.00
Total for Organization

* Total To Be Remitted:

* III. I authorize GACCP to officially release my name, address and phone number for the nature of conducting business of this organization.
* IV. By agreeing to become a Georgia Association of Community Care Provider member, I agree to adhere to the GACCP code of ethics.
* Name:
* Date:
Please type the code shown in the image below: