Contact address Nominee’s Affiliation(s) Specify Profession, organization representing, role in Indicate ALL categories organization, line of business, mission, populations that apply that are representing. relevant to CSAC work Public Health e.g., Research, academic Check if Applicable __ Health Department if Applicable __ e.g., State, regional, local Government Policy Check if Applicable __ Employee e.g., DHMH, regional, etc. Provider Representative e.g., Hospital rep, physician/practitioner (primary Check if Applicable __ care, specialist), Representative Check if Applicable __ e.g., MCO, Medicare, Medicaid, etc. Consumer Policy Check if Applicable __ Advocate e.g., non-government health policy advocate Wraparound/Social e.g., transportation, financial or other assistance, etc. Check if Applicable __ Service Providers Behavioral Health e.g., provider, advocate if Applicable __ Health Literacy Expert e.g., researcher, educator, etc. Check if Applicable __ Long Term Care e.g., provider type, advocate, etc. if Applicable __ Community Based e.g., care coordination provider, Check if Applicable __ Organization (CBO) Individual/Consumer e.g., individual representing themselves, unaffiliated Check if Applicable __ Representative with organization, hospital Patient Family Advisory Committee member, etc. Other Check if Applicable __ Specify Other Check if Applicable __ Specify Narrative description of Describe how the Nominee’s experience Nominee’s expertise, and background experience, and diversity represented. will contribute CSAC (enter in or attach- 2 page limit) Narrative description of Include description of Nominee’s connection to health care policy and and interest in consumer reform issues of interest. engagement in health Please refer to CSAC care. charge document. (enter in or attach- 1 page limit)
Contact address Nominee’s Affiliation(s) Specify Profession, organization representing, role in organization, line of business, mission, populations representing. Indicate ALL categories that apply that are relevant to CSAC work Public Health e.g., Research, academic Check if Applicable __ Health Department e.g., State, regional, local if Applicable __ Government Policy Employee e.g., DHMH, regional, etc. Check if Applicable __ Provider Representative e.g., Hospital rep, physician/practitioner (primary care, specialist), Check if Applicable __ Representative e.g., MCO, Medicare, Medicaid, etc. Check if Applicable __ Consumer Policy Advocate e.g., non-government health policy advocate Check if Applicable __ Wraparound/Social Service Providers e.g., transportation, financial or other assistance, etc. Check if Applicable __ Behavioral Health e.g., provider, advocate if Applicable __ Health Literacy Expert e.g., researcher, educator, etc. Check if Applicable __ Long Term Care e.g., provider type, advocate, etc. if Applicable __ Community Based Organization (CBO) e.g., care coordination provider, Check if Applicable __ Individual/Consumer Representative e.g., individual representing themselves, unaffiliated with organization, hospital Patient Family Advisory Committee member, etc. Check if Applicable __ Other Specify Check if Applicable __ Other Specify Check if Applicable __ Narrative description of Nominee’s experience and background represented. Describe how the Nominee’s expertise, experience, and diversity will contribute CSAC (enter in or attach- 2 page limit) Narrative description of Nominee’s connection to and interest in consumer engagement in health care. Include description of health care policy and reform issues of interest. Please refer to CSAC charge document. (enter in or attach- 1 page limit)