2021 Provider Member Application
To apply for provider membership, an entity must:

-Currently contract to provide CDPA services;

-Allow consumers to recruit, hire, train, supervise and terminate the personal assistants they choose to work with; and

-Respect the autonomy of the consumer as an empowered individual who has the authority to direct his or her own care.

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Agency Name *
Agency Address *
Agency Phone Number *
Agency Website Address
Name and Email of Executive Director *
Name and Email of CDPA Contact *
Communications will be directed to this person unless otherwise indicated.
Agency's Total Annual CDPA Revenue *
CDPAANYS Annual Dues are based on the agency’s total CDPA revenue from your most recently completed fiscal year. This section must be reviewed and verified by an independent accountant or auditor who has familiarity with the applying fiscal intermediary’s records. Using the table below, please identify your agency’s total:
Name of Independent Accountant or Auditor *
Accountant or Auditor Firm/Company *
Attestation of Annual Dues *
Required
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