2019 Provider Member Renewal Form
Please complete this renewal form for CDPAANYS Provider Membership.
Agency Phone Number
Agency Website Address
Name and Email of Executive Director
Name and Email of CDPA Contact
Communications will be directed to this person unless otherwise indicated.
Agency's Total Annual CDPA Revenue
CDPAANYS Annual Dues are based on the agency’s total CDPA revenue from your most recently completed fiscal year. This section must be reviewed and verified by an independent accountant or auditor who has familiarity with the applying fiscal intermediary’s records. Using the table below, please identify your agency’s total:
Less than $2.5 Million: $4,000 annually or $1,000 per quarter
$2.5 to $5 Million: $6,250 annually or $1,562.50 per quarter
$5 to $10 Million: $8,750 annually or $2,187.50 per quarter
$10 to $15 Million: $10,750 annually or $2,687.50 per quarter
$15 to $20 Million: $12,750 annually or $3,187.50 per quarter
$20 to $25 Million: $14,750 annually or $3,687.50 per quarter
$25 to $30 Million: $17,250 annually or $4,312.50 per quarter
$30 to $35 Million: $19,750 annually or $4,937.50 per quarter
$35 to $40 Million: $22,250 annually or $5,562.50 per quarter
$40 to $45 Million: $24,750 annually or $6,187.50 per quarter
$45 to $50 Million: $27,250 annually or $6,812.50 per quarter
$50 Million or Greater: $30,000 annually or $7,500 per quarter
Name of Independent Accountant or Auditor
Accountant or Auditor Firm/Company
Attestation of Annual Dues
I verify that the Annual Dues information and accountant/auditor information provided is correct.
Never submit passwords through Google Forms.
This form was created inside of CDPAANYS.
Terms of Service