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Request to Schedule an Informational Presentation
Providers and Community-Based Organizations may request informational sessions to learn more about the Medicaid Managed Care program. Please fill out the required fields below. Once complete, a member of the Medicaid Managed Care staff will contact you to make final arrangements.
* Indicates required information
Organization Name:
*
Address 1:
*
City:
*
State:
*
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AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
ZIP:
*
First Name:
Last Name:
Email:
*
Phone:
*
Best Time to Contact You
*
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8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
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- Select -
8:00 am
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
Mon
Tue
Wed
Thur
Fri
Desired Outreach Event Date:
*
Purpose of the Event:
*
- Select -
State Agency
County Agency
Member - General
Member - Pregnancy
Member - Special Needs
Member - Seniors
CBO - Training
Community Presentation
Provider Presentation
Health Fairs
Other
CBO Presentation
Anticipated Number of Attendees:
*
- Select -
1-10
11-20
21-50
50+
Additional Information:
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