2026-2027 SNF/ALF/EDWCM Membership Application
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1.
Select the category of membership for which you are applying:
*
Assisted Living Community/Personal Care Home Membership - Annual Dues: $27.30 per licensed bed (includes NCAL dues of $11.80/bed & GHCA dues of $15.50/bed)
E&D Waiver Case Management Membership (SOURCE/CCSP) - Annual Dues: $650 - Case Load < 500, $1,000 - Case Load > 500
Skilled Nursing Center Membership - Annual Dues: $80.31 per licensed bed (includes AHCA dues of $23.12/bed & GHCA dues of $57.19/bed)
2.
Facility/Agency Name
*
3.
Facility/Agency Address:
*
Address Line 1
Address Line 2
City
State
Zipcode
Phone Number
Fax Number
Website
4.
Primary Contact Person:
*
First Name
Last Name
Email Address
FOR E&D WAIVER CASE MANAGEMENT MEMBERSHIP APPLICANTS ONLY
5.
Are you a SOURCE or CCSP provider?
For E&D Waiver Case Management membership applicants only
SOURCE
CCSP
Both SOURCE and CCSP
6.
SOURCE Case Load:
For E&D Waiver Case Management membership applicants only
7.
SOURCE Medicaid Provider Number:
For E&D Waiver Case Management membership applicants only
8.
CCSP Case Load:
For E&D Waiver Case Management membership applicants only
9.
CCSP Medicaid Provider Number:
For E&D Waiver Case Management membership applicants only
