Apply to Become a State Liaison

First Name:
Last Name:
Phone Number:
E-mail:
State:
Name of Practice:
Practice Website:
Practice Address:
Specialty:	Physical Medicine and Rehabilitation Neurology
Training program attended for residency:
Type of Practice:	Private Practice Hospital-Based Group University-Based Group Government-Based Group
If you are in private practice, check all descriptors that apply:	1-2 Physicians 3-5 Physicians 6-15 Physicians 15+ Physicians Single Specialty Multispecialty
Which payors does your practice bill the most?:
Do you work with payors in any of the following capacities?:	I work as a medical director for an insurance company I am a Carrier Advisory Committee (CAC) member I work as a consultant for an insurance company I develop coverage policies I review new technology I review claims for fraudulent billing None of the above Other work with payors
Please explain:
Discuss why you are interested in becoming a state liaison (1-2 paragraphs).:
Are you willing to meet with and work to develop relationships with key state and federal legislators and other elected officials as needed?:	Yes No
Have you had any contact with any state and/or federal legislators? Or any other elected officials?:	Yes No
If yes, please explain:
Do you have any existing relationships with any state and/or federal legislators? Or any other elected officials?:	Yes No
If yes, please explain:

American Association of Neuromuscular & Electrodiagnostic Medicine