Organization: __________________________________________________________________________________ Address: ______________________________________________________________________________________ City: _______________________________ State: _______ Zip: _____________ County: ______________________ Phone: ____________________ Fax: ____________________ Website: __________________________________ 2016/17 Full Provider Membership Application July 1, 2016 through June 30, 2017 Please update all information and return to RCPA, 777 E Park Dr, Ste 300, Harrisburg, PA 17111. 2015/16 FY total/gross budgeted revenue (for hospitals– total net revenue) for all services identified in Step 1 $____________________________ Organizations composed of multiple corporations should combine all relevant budgets. Include all appropriate revenue regardless of funding source. Only include services located within Pennsylvania. Please select all that apply: Adult Children Autism Autism Brain Injury Brain Injury Criminal Just. Child Welfare D&A D&A IDD IDD Medical Rehab Juvenile Just. MH Med Rehab PAS MH Residential Residential Service Coord Vocational Supports Coord Vocational For first year members Total amount from Step 3 $_________ x .50 = $__________ For second year members Total amount from Step 3 $_________ x .75 = $__________ Please note for full-year, non-prorated dues: Minimum dues—$969, Maximum dues—$25,500 This serves as your invoice. Approximately 27.5% of your membership dues are not tax deductible. Is your organization interested in joining the National Council in 2016/17 for a discounted rate? Yes Add $450 for budget under $3 million No Add $950 for budget of $3—$8 million Add $1,450 for budget over $8 million Total = $______________ I hereby attest that the above budget information upon which dues are based is correct and complete to the best of my knowledge. Signature: ___________________________________________ Date: ____________________________ Step 1: Services Offered Step 2: Calculate Gross Revenue Step 4: New Member Discount (if applicable) Step 5: National Council for Behavioral Health Step 6: Acceptance of Membership Criteria and Verification by CEO/Executive Director Name Title Email CEO/Executive Director _______________________ _______________________ _______________________ Correspondence Contact Receives updates _______________________ _______________________ _______________________ Renewal Contact Receives renewal information _______________________ _______________________ _______________________ RCPA Dues Amount $ ______________________________ Step 3: RCPA Membership Dues
2016/17 Full Provider Membership Application July 1, 2016 through June 30, 2017
Please update all information and return to RCPA, 777 E Park Dr, Ste 300, Harrisburg, PA 17111.
2015/16 FY total/gross budgeted revenue (for hospitals– total net revenue) for all services identified in Step 1
$____________________________
Organizations composed of multiple corporations should combine all relevant budgets.
Include all appropriate revenue regardless of funding source. Only include services located within Pennsylvania.
Please select all that apply: Adult Children
Autism Autism
Brain Injury Brain Injury
Criminal Just. Child Welfare
D&A D&A
IDD IDD
Medical Rehab Juvenile Just.
MH Med Rehab
PAS MH
Residential Residential
Service Coord Vocational
Supports Coord
Vocational
For first year members Total amount from Step 3 $_________ x .50 = $__________ For second year members Total amount from Step 3 $_________ x .75 = $__________
Please note for full-year, non-prorated dues:
Minimum dues—$969, Maximum dues—$25,500
This serves as your invoice.
Approximately 27.5% of your membership dues are not tax deductible.
Is your organization interested in joining the National Council in 2016/17 for a discounted rate?
Yes Add $450 for budget under $3 million
No Add $950 for budget of $3—$8 million Add $1,450 for budget over $8 million Total = $______________
I hereby attest that the above budget information upon which dues are based is correct and complete to the best of my knowledge.
Service Coord Dir ______________________________________ _______________________________________
Supports Coord Dir ______________________________________ _______________________________________
Vocational Director ______________________________________ _______________________________________
Counties Served:
Our organization will accept referrals from all Pennsylvania counties.
Individuals served (Estimated number of persons served in all
programs on an annual basis): _____________
Number of program sites/locations
for your organization:________
Number of employees: Full Time: _____________
Part Time: _____________
Volunteers: _____________
County Abbreviations ADA - Adams ALL - Allegheny ARM - Armstrong BEA - Beaver BED - Bedford BER - Berks BLA - Blair BRA - Bradford BUX - Bucks BUT - Butler CMB - Cambria CRN - Cameron CAR - Carbon CEN - Centre CHE - Chester CLA - Clarion CLE - Clearfield CLI - Clinton COL - Columbia CRA - Crawford CUM - Cumberland DAU - Dauphin DCO - Delaware ELK - Elk ERI - Erie FAY - Fayette FOR - Forest FRA - Franklin FUL - Fulton GRE - Greene HUN - Huntingdon INN - Indiana JEF - Jefferson JUN - Juniata LAC - Lackawanna LAN - Lancaster LAW - Lawrence LEB - Lebanon LEH - Lehigh LUZ - Luzerne LYC - Lycoming MCK - McKean MER - Mercer MIF - Mifflin MOE - Monroe MGY - Montgomery MTR - Montour NHA - Northampton NUM - Northumberland PER - Perry PHI - Philadelphia PIK - Pike POT - Potter SCH - Schuylkill SNY - Snyder SOM - Somerset SUL - Sullivan SUS - Susquehanna TIO - Tioga UNI - Union VEN - Venango WAR - Warren WAS - Washington WAY - Wayne WES - Westmoreland WYO - Wyoming YOR - York
