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2023 OPRA Sponsored Provider Membership Application
Welcome to the Ohio Provider Resource Association!
We hope you enjoy being an OPRA Member. Please take full advantage of all the great benefits OPRA has to offer!
Reminders and Details:
OPRA’s Membership Year is from January 1 through December 31.
Please complete the following information as accurately as possible to help us better serve you - Thank you!
If you have any questions regarding your OPRA Membership, please feel free to contact us at (614) 224-6772.
Organization Information
Type
choose one
For Profit
Non-Profit
Independent Provider
Organization Name
Website
Main Phone
Physical Address
CHECK if Billing address and Physical address are the SAME
Address
City
State
Zip
Billing Address
Please provide Billing Address
ONLY if different from above.
CHECK if Billing address is DIFFERENT from Physical address
Address
City
State
Zip
Your Contact Information
First Name
Last Name
Title
Email
Organization's CEO, Executive Director or Owner (if different from above)
First Name
Last Name
Title
Email
Billing Contact (if different from above)
First
Last
Title
Email
Name of County Board Sponsoring Your OPRA Membership
County Board Name
Additional Organization Information
Please list all other subsidiary entities which your organization owns that fall under this membership:
Total # Employees, in all locations:
Approximately, how many individuals do you serve a year?
Please select all applicable services your organization provides: (use SHIFT, CONTROL or COMMAND to multi-select)
select all that apply
Adult Day Support
Behavioral Health Care (OMHAS)
Early Intervention Services
HCBS Waiver Career Planning
HCBS Waiver Group Employment Supports
HCBS Waiver Individual Employment Supports
HCBS Waiver Nursing
HCBS Community Respite
Home Health Care/Hospice
HPC
ICF/IDD
Medicaid Funded Therapies
Multi-System Youth Services
NMT
OOD Vendor
Remote Support
Shared Living
Vocational Habilitation
Please choose the following counties you provide services in:
All 88 Counties
Adams
Allen
Ashland
Ashtabula
Athens
Auglaize
Belmont
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Jefferson
Knox
Lake
Lawerence
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Meigs
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
Terms and Conditions
By signing the form below, the Organizational Representative understands that an OPRA Staff member may confirm subscriptions and inquire about any additional employee subscriptions. The Organizational Representative also consents to the organization’s listing as an OPRA Member on any/all published materials.
I certify that the information on this form is current, accurate, and complete.
Signature
Date
?
A LOOK AHEAD
OPRA offers a special 35% discount as an introductory rate for first year members. Second year OPRA members and beyond pay the full standard dues rate for OPRA Membership. We encourage new OPRA members to talk with other members about the value of OPRA membership and how you can get the best return on your dues investment.
- denotes required fields
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