Provider - SCALA

Provider Membership Application

All assisted living or residential care communities. Dues are based on number of DHEC licensed beds.

Company/Organization Name*
Username*
Password*
Enter Password Confirm Password
First Name*
Last Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Total # of licensed beds*
Total # of licensed beds*
Date of last DHEC Inspection
MM slash DD slash YYYY
Type of Ownership
Do you accept Medicaid?
- Yes
- No
Operations Director/Regional Director
Email
I (we) hereby submit the information above for the consideration of the Membership Committee and/or theBoard of Directors and apply for membership with the SC Assisted Living Association. I (we)agree to comply with all rules and regulations as set forth by SCALA standards including the bylaws and Code of Ethics. Please submit method of payment at time of application and payment will only be processed after approval for membership. Membership will be reviewed and an answer will be given within seven (7) days of submission. Please note 25% of SCALA dues are allocated for lobbying, consulting & legislative efforts and are not allowable as a business expense.
Signature of Approval*
Date*
MM slash DD slash YYYY
Payment
Bed Price*
Price:
17 Beds or less*
Price:
Flat Rate
Total
$0.00
Payment Method*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Comments
This field is for validation purposes and should be left unchanged.

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