Renew Your Membership Membership Renewal Form "*" indicates required fields Please fill out the form below. When complete use the submit button at the bottom of the page.Agency Name:* Member Representative:* Title:* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone:*Fax Number:*Email:* Website:* Corporate Status:* For Profit – Corporation For Profit – Individual For Profit – Partnership Non Profit – Corporation Non Profit – Other Please complete the following information for the person who is responsible for billing and financial management in your organization. Contact Person* Title:* Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone:*Fax Number:*Email:* 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 No If yes, please describe:*Counties your agency provides services in:*Please indicate which MaineCare reimbursed services your agency provides. Covered Services under Section #13:(please note children and/or adults)Number of individuals served under Section #13:Number of employees performing covered services under Section #13:Covered Services under Section #19:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #19:Number of employees performing covered services under Section #19:Covered Services under Section #20:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #20:Number of employees performing covered services under Section #20:Covered Services under Section #21:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #21:Number of employees performing covered services under Section #21:Covered Services under Section #28:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #28:Number of employees performing covered services under Section #28:Covered Services under Section #29:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #29:Number of employees performing covered services under Section #29:Covered Services under Section #50:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #50:Number of employees performing covered services under Section #50:Covered Services under Section #65:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #65:Number of employees performing covered services under Section #65:Covered Services under Section #97 – Appendix F:(ex: agency home supports, community supports, etc.)Number of individuals served under Section #97 – Appendix F:Number of employees performing covered services under Section #97 – Appendix F:Other IDD Services:(ex: agency home supports, community supports, etc.)Number of individuals served under other IDD services:Number of employees performing covered services under other IDD services:Please complete all applicable information requested regarding total revenue your organization or business receives that serve people with intellectual and developmental disabilities in the State of Maine. What is your total MACSP qualifying revenue from FY '21, or calendar year-end 2020, or your last 990/Audit.* Include revenues from Section 13, 19, 20, 21, 28, 29, 50 (ICF), 65, 106 & PNMI and IDD revenue from any related entities.Dues Level* Based on your total IDD revenue, select the corresponding dues level for your agency. An invoice for this amount will be sent to your organization.Dues Level FY 2021-2022* Level I 0-$249,999 Dues: $600 Level II $250,000-$499,999 Dues: $1,115 Level III $500,000-$999,999 Dues: $1,550 Level IV $1,000,000-$1,499,999 Dues: $1,900 Level V $1,500,000-$1,999,999 Dues: $2500 Level VI $2,000,000-$3,499,999 Dues: $2750 Level VII $3,500,000-$4,999,999 Dues: $2950 Level VIII $5,000,000-$6,999,999 Dues: $3250 Level IX $7,000,000-$8,999,999 Dues: $3500 Level X $9,000,000-$11,499,999 Dues: $3800 Level XI $11,500,000-$13,999,999 Dues: $4,100 Level XII $14,000,000-$17,999,999 Dues: $4,450 Level XIII $18,000,000-$24,999,999 Dues: $4,850 Level XIV $25,000,000-$39,999,999 Dues: $5,250 Level XV $40,000,000 + Dues: $6000 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)* Reset signature Signature locked. Reset to sign again 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:* MM slash DD slash YYYY Name:* CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
