MassHealth Logo - Gray and White

Request For Member Education In-Service

Contact Information

Agency

First Name    Last Name

Address

City     State      Zip

Phone     E-mail


When (date requesting)?            

Time: From To

Other Agencies attending


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

Issues that you want reviewed

Purpose of in-service


Note: Once requested form is received, a member education representative will follow up with you.