Become a New Member

Full Member – New Membership Form (FY 2023)

This form is for providers who are applying for Full Membership as of July 1, 2022.

"*" indicates required fields

Please fill out the form below. When complete use the submit button at the bottom of the page.

Agency Name:*

Address*

Street Address Address Line 2 City State ZIP Code

Website:*

Telephone:*

Fax Number:*

Corporate Status:*

For Profit – Corporation

For Profit – Individual

For Profit – Partnership

Non Profit – Corporation

Non Profit – Other

Agency Provider ID (NPI):

NPI +3 locations numbers NOT needed.

Year Agency Established Services in Maine:

Designated Voting Representative Name:*

The individual designated by your organization to vote on MACSP business.

Title:*

Designated Voting Member Email:*

Designated Voting Member Telephone:*

Please complete the following information for the person who is responsible for billing and financial management in your organization.

Contact Person for Invoicing:*

Title:*

Address:*

Street Address Address Line 2 City State ZIP Code

Contact for Invoicing Telephone:*

Contact for Invoicing Email:*

Name of individual(s) listed as Administrators on the Agency’s Provider Agreement and any licenses held by the organization.*

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

Agency does not hold any of these licenses

ICF-ID

Assisted Housing

Behavioral Health

Childcare

Other

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

Yes

If yes, please describe:

Select the counties your agency provides services in:*

Agency Provided Covered Services

Please describe the covered services provided by your agency, including number of individuals served and number of employees.

Please select the Covered Services under Section #13 provided by your agency:

Adult Case Management

Children’s Case Management

Adult and Child Case Management

Number of ADULTS served under Section #13:

Number of CHILDREN served under Section #13:

Number of employees performing covered services under Section #13:

Please select the Covered Services under Section #18 provided by your agency:

Number of individuals served under Section #18:

Number of employees performing covered services under Section #18:

Please select the Covered Services under Section #19 provided by your agency:

Number of individuals served under Section #19:

Number of employees performing covered services under Section #19:

Please select the Covered Services under Section #20 provided by your agency:

Number of individuals served under Section #20:

Number of employees performing covered services under Section #20:

Please select the Covered Services under Section #21 provided by your agency:

Number of individuals served under Section #21:

Number of employees performing covered services under Section #21:

Do not include staff working in Agency Group Homes. Please provide that number in next question.

Number of employees working in Agency Group Homes:

Number of Agency Group Home locations (as of July 1, 2022)::

# of agency group home locations that are open and actively providing Section 18 or Section 21 services as of July 1, 2022.

Please select the Covered Services under Section #28 provided by your agency:

Treatment Services

Specialized Services

BCBA Services

Number of children served under Section #28:

Number of employees performing covered services under Section #28:

Please select the Covered Services under Section #29 provided by your agency:

Number of individuals served under Section #29:

Number of employees performing covered services under Section #29:

Please select the Covered Services under Section #50 provided by your agency:

ICF-MR Development Training (Community Supports/Day) Program

Per Diem Residential Services

Pharmacy Services

Physical Therapy and Occupational Therapy

Speech and Hearing Services

Supplies and Equipment Billed by Supplier or Pharmacy

Other Services

Number of individuals served under Section #50:

Number of employees performing covered services under Section #50:

Please select the Covered Services under Section #65 provided by your agency:

Children’s Home and Community Based Treatment

Children’s Behavioral Health Day Treatment

Number of individuals served under Section #65:

Number of employees performing covered services under Section #65:

Please select the Covered Services under Section #97 – Appendix F provided by your agency:

Per Diem Residential Services

Pharmacy Consultation

RN Consultation

Dietary Consultation

Number of individuals served under Section #97 – Appendix F:

Number of employees performing covered services under Section #97 – Appendix F:

Please select the Covered Services under Section #102 provided by your agency:

Clinical Assessment and Reassessment

Intensive Integrated Neuro-rehabilitation

Neuro-behavioral Rehabilitation

Home and Community Reintegration

Self-Care/Home Management

Number of individuals served under Section #102:

Number of employees performing covered services under Section #102:

Does your agency operate a developmental pre-school?

Yes

Number of employees in your developmental preschool program?

Number of students in your developmental preschool program?

Does your agency operate a Kindergarten – Grade 5 program?

Yes

Number of employees in your K – 5 program?

Number of students in your K – 5 program?

Other IDD Services:

Please list the Mainecare Section # and service type for other IDD services agency provides.

Number of individuals served under other IDD services:

Number of employees performing covered services under other IDD services:

Membership Dues

Please complete all applicable information requested regarding total revenue your organization or business receives for providing services to children and adults with intellectual disabilities, Autism and Brain Injuries in the State of Maine. MACSP defines qualifying revenue as revenue generated by the agency from the provision of any of the services listed in the Mainecare Benefits Manual (MBM) Chapters 2 and 3 under Sections 13, 18, 19, 20, 21, 28, 29, 50, 97-Appendix F, and 102.

What is your total MACSP qualifying revenue from FY '22, or calendar year-end 2021, or your last completed audited financial statement?*

Include revenues from Section 13, 18, 19, 20, 21, 28, 29, 50 (ICF), 65, 97-F (PNMI), 102 and IDD revenue from any related entities.

Dues Level*

Select the corresponding dues level for your agency. An invoice for this amount will be sent to the invoicing contact listed on this application, with a cc to the designated voting member for your organization. Payment – Payment is due within 30 days of invoice receipt or no later than August 30, 2022. Details will be provided in the invoice sent within seven business days of submitting this renewal form.

Dues Level FY 2022-2023*

MACSP Members commit to the following prescribed standards and principles of quality, which apply to the supports provided in the professional relationship with persons served, parents and guardians of persons served, colleagues, related agencies and professions, and the community at large.

AS A MEMBER OF MACSP, THIS ORGANIZATION PLEDGES TO:

Provide supports and services in a manner which 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)*

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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