Become a New Member

Full Member – FY 2027 New Member Application

This form is for provider organizations applying to join the Association for membership year 2027 (July 1, 2026 – June 30, 2027). To be eligible for MACSP membership, your organization must be a provider of Sections 13, 18, 19, 20, 21, 28, 29, 50, 92-Behavioral Health Homes, 97-Appendix F, 102 or Department of Education (DOE) supported Special Purpose Private School (SPPS) programs. Additionally, your organization must have provided direct services for 12 consecutive months. Please complete and submit your MACSP Membership Application. Required fields are marked with an asterisk (*). When complete, use the submit button at the bottom of the page. Once submitted, you will receive a confirmation email within seven business days. If you have any questions, please contact: Becca Emmons, Membership Coordinator: e: membercoord@meacsp.org

Agency Name(Required)

Website(Required)

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

My organization has provided direct services for at least 12 consecutive months.(Required)

Yes, my organization has provided direct services for at least 12 consecutive months.

No, my organization is an approved provider but has not yet provided direct services for 12 consecutive months.

To be eligible for MACSP membership, the provider must have provided direct service for 12 consecutive months. Provider organizations that are approved, but have not yet provided direct service for 12 consecutive months, are not eligible for MACSP membership.

Select the MACSP Region in which the agency's Primary Administration office is located.(Required)

Central Region: Somerset, Kennebec, Sagadahoc, Lincoln, Waldo, and Knox counties

Northern Region: Aroostook County

Penquis-Downeast Region: Piscataquis, Penobscot, Washington, Hancock counties

Southern Region: York and Cumberland counties

Western Region: Oxford, Androscoggin, and Franklin counties

Corporate Status(Required)

For Profit – Corporation

For Profit – Individual

For Profit – Partnership

Non-Profit – Corporation

Non-Profit – Other

If For Profit – list all owners and partners (first and last name) below:

Is your organization a subsidiary of, or affiliated with, another organization? If yes, list here.

Designated Voting Representative Name:*(Required)

First Last

Please provide the full name of the individual in your organization who is authorized to vote on behalf of your agency in MACSP matters.

Designated Voting Member Professional Title:(Required)

Email(Required)

Phone(Required)

Proxy Voting Representative Name:*(Required)

First Last

Please provide the name of the individual who is authorized to vote on behalf of your organization when the designated voting representative is unavailable. A proxy may only vote with the express consent of the designated voting representative.

Proxy Voting Member Professional Title:(Required)

Email(Required)

Phone

Name of Contact Person for Invoicing:*(Required)

First Last

Please provide the name and contact information for the individual responsible for billing and financial matters within your organization. This person will receive the membership invoice and any related communications.

Invoicing Contact Professional Title:(Required)

Email(Required)

Phone

Has your organization applied for MACSP membership in the past, or been a past MACSP member?(Required)

Yes

Unsure

Has your organization applied to become a MACSP member in the recent 3 years, or been a MACSP member organization whose membership lapsed between 2023 – 2026?

Has anyone in the management of this organization been involved in a license revocation or forced to close any other organization delivering similar services?(Required)

Yes

If yes, please explain.

Select all the counties in which your agency provides services.(Required)

Has your agency received 10-144 CMR Ch 108 Home and Community Support Service Licensure?(Required)

The agency does not provide services that require a Chapter 108 license.

Yes

Submitted to the State, but have not yet received a response.

If yes, please provide agency HCA # here:

If yes, select all of the HCS licensed services your agency provides.

Case management or care coordination

Home support

Community support

Employment support

Personal support

Residential services

If no, please tell us more:

Does the agency hold any of the following licenses? (check all that apply)(Required)

Agency does not hold any of these licenses

ICF-ID

Behavioral Health Section 65

Children’s Services Section 28

Childcare

Other

Does your agency hold any formal accreditations? If yes, please share those accreditations here:

Example accreditations: Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Quality and Leadership (CQL), and The Joint Commission, Accreditation Commission for Health Care (ACHC), National Association for the Dually Diagnosed (NADD), NADSP (National Alliance for Direct Support Professionals), ACRE (Association of Community Rehabilitation Educators)

As of July 1, 2026 how many people does your agency employ?(Required)

By best estimate, how many employees are full-time?

By best estimate, how many employees are part-time?

Which MaineCare sections fund the services provided by your agency?(Required)

Please select all the Mainecare Sections provided by your agency.

Which of the following service categories does your organization provide?

Adult Case Management – # of people supported

Adult Case Management – # of Case Managers

Children's Case Management – # of children supported

Children's Case Management – # of Case Managers

Community Support Services – # of people supported

Community Support Services – # of direct support staff

Employment & Work Supports – # of people supported

Employment & Work Supports – # of direct support staff

Shared Living Oversight – # of people supported

Shared Living Oversight – # of contracted providers

Shared Living Oversight – # of locations

Shared Living Oversight – # of agency staff

Section 21 Agency Home Supports (group home) – # of people supported

Section 21 Agency Home Supports (group home) – # of direct support staff

Section 21 Agency Home Supports (group home) – # of locations

Quarter Hour Home Support Services – # of people supported

Quarter Hour Home Support Services- # of direct spport staff

Remote Support Services – # of people supported

Remote Supports – # of monitoring staff

Behavioral Health Homes – Section 92 – # of children supported

Behavioral Health Homes – Section 92 – # of care coordination staff

Children's Services – Section 28 – # of children supported

Children's Services – Section 28 – # of direct spport staff

Check off Section 28 services agency provides:

Rehabilitative and Community Support Services (RCS)

Specialized Services

BCBA Services

Children’s Services – Section 65 – # of children supported

Children’s Services – Section 65 – # of direct spport staff

Check off Section 65 services agency provides:

Home and Community Treatment (HCT)

Day Treatment

Brain Injury Services – Section 18 – # of people supported

Brain Injury Services – Section 18 – # of direct spport staff

Section 18 Agency Home Support (group home) – # of people supported

Section 18 Agency Home Support (group home) – # of direct support staff

Section 18 Agency Home Support (group home) – # of locations

Rehabilitative Services – Section 102 – # of people supported

Rehabilitative Services – Section 102 – # of rehabilitative staff

ICF/IID Services – # of people supported

ICF/IID Services – # of direct spport staff

ICF/IDD Services – # of locations

PNMI Appendix F – # of people supported

PNMI Appendix F – # of direct spport staff

PNMI Appendix F – # of locations

Special Purpose Private School – Total # of children enrolled

Special Purpose Private School – Total # of staff

Special Purpose Private School – # of locations

SPSS – PreK – # of students enrolled

SPSS – Grades K to 5 – # of students enrolled

SPSS – Grades 6 to 12 – # of students enrolled

Other IDD Services

If not listed above, please share other IDD services provided, # of people supported and # of direct support staff.

What is your total MACSP qualifying revenue from FY '26, or calendar year-end 2025, or your last completed audited financial statement?*(Required)

Numbers Only – No special characters, commas or decimal points. For the purposes of determining dues, MACSP defines qualifying revenue as any revenue your agency generates from services listed in the MaineCare Benefits Manual (MBM), Chapters II and III, including: Sections 13, 18, 19, 20, 21, 28, 29, 50, and 97 (Appendix F) Section 92 (Behavioral Health Homes for Children), Section 102 and revenue from Department of Education-funded Special Purpose Pre-School (SPPS) programs. Please include all revenue from these sources when completing the dues calculation.

Membership Dues – select level that corresponds with qualifying revenue.(Required)

Level I 0-$999,999 Dues: $1,500

Level II $1M to $1,999,999 Dues: $3,000

Level III $2M – $6,999,999 Dues: $4,500

Level IV $7M – $11,999,999 Dues: $6,500

Level V $12M – $17,999,999 Dues: $8,500

Level VI $18M – $29,999,999 Dues: $10,000

Level VII $30M+ Dues: $12,000

For the purposes of determining dues, MACSP defines qualifying revenue as any revenue your agency generates from services listed in the MaineCare Benefits Manual (MBM), Chapters II and III, including: Sections 13, 18, 19, 20, 21, 28, 29, 50, and 97 (Appendix F) Section 92 (Behavioral Health Homes for Children), Section 102 and revenue from Department of Education-funded Special Purpose Private (SPPS) programs. Please include all revenue from these sources when completing the dues calculation.

On behalf of my agency, I pledge to support the MACSP Principles, Standards, and Quality Pledge.(Required)

Provide supports and services in a manner that exemplifies integrity, compassion, and respect for individual differences and choice;
Provide supports and services designed to meet the needs of the individual supported with emphasis on promoting choice, self-determination, inclusion, growth, and development;
Respect the privacy of the individual supported and protect the rights of confidentiality;
Give preference to professional responsibility over any personal interest;
Advocate for standards that promote outcomes of quality;
Advocate for and provide supports and services that best assure the health and safety of the individual supported;
Encourage and advocate for the protection of the individual supported and the community at-large against unethical and/or illegal practices or actions by other individuals or organizations engaged in providing supports;
Not discriminate because of race, color, religion, age, sex, sexual orientation, disability, or national ancestry and work to eliminate or prevent such discrimination;
Promote inclusion and equitable treatment of all people including those receiving supports, staff, friends, families, and the community at-large;
Serve as a responsible steward for public and private funds;
Contribute to MACSP Membership ideas, findings, concepts, understanding, knowledge, and practice which further develop education and expanded knowledge of leading practices in providing high quality supports and services to individuals with disabilities;
Keep MACSP information and materials confidential without further dissemination or distribution to employees without a need or to any third parties without the express written permission of MACSP; and
Be accountable for statements made with respect to individuals with disabilities and distinguish clearly statements and actions made as an individual and, when authorized by the MACSP Board of Directors, those made as a representative of MACSP.

CERTIFICATION SIGNATURE (sign in the box below)(Required)

I certify that the information provided in this application is accurate and complete to the best of my knowledge. The undersigned hereby agrees that it will in all respects conform to and abide by MACSP’s Quality Pledge and Bylaws, and all amendments hereafter made thereto.

Date

Name

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