Contact Information

Agency

First Name   

Last Name

Address

City     State      Zip

Phone     Ext.

E-mail


Service Request Information

Requesting Date

       

Requesting Time

From To

Additional Agencies Attending?

If yes, please provide names of additional agencies attending?

Who will be attending (e.g., social workers, outreach workers) & How Many?

Issues that you want reviewed.

Purpose of in-service request.


Please note: Upon receipt of the “Request For Member Education In-Service” form a MassHealth member education representative will follow up with you. MassHealth Logo - Gray and White