Application - Join PHA - Pennsylvania Homecare Association

Locate a Homecare Provider

Online Application
Step 1 of 5

Please fill out the form below to start your online application. It will take about 10 minutes to complete the application. If you need to add additional offices, please refill out this form for each office. Thank you. Fields in Red are required.

Contact Information
Agency Name
Primary Contact Name
Title
Email Address
Address 1
Address 2
City
State
Zip Code
County Location
Phone	- -
Fax	- -
Agency Web Site Address

Membership Information

Type of Membership (please check one of these)

Affiliate Membership $600 (members that provide services to homecare agencies and do not provide services in the home)

Organizational memberships (check revenue range below)

	$0 - $300,000	$1,000
	$300,001-$900,000	$1,500
	$900,001-$1,500,000	$2,000
	$1,500,001-$3,000,000	$2,500
	$3,000,001-$4,500,000	$3,000
	$4,500,001-$6,000,000	$3,500
	$6,000,001-$7,500,000	$4,000
	$7,500,001-$9,000,000	$4,500
	$9,000,001-$10,500,000	$5,000
	$10,500,001-$12,000,000	$5,500
	$12,000,001-$15,000,000	$6,000
	$15,000,001-$20,000,000	$6,500
	$20,000,001+	$7,000
	Additional Location Fee $100

Number of Employees
	# of Full-time Employees
	# of Part-time Employees

Misc Information (Check all that apply)
		Please contact me about how to advertise with PHA
		I want a direct web link from the PHA site to my agency site - $100 (Your agency will be listed on the following PHA web sites - www.pahomecare.org, www.pacareathome.org, www.pahomecareresource.org.)
		Medicare - certified
		Private Duty/Continuous
		Other (Adult Day, HME)
		JCAHO Accreditation
		CHAP Accreditation