Apply to Become a State Liaison

Full Name*

Phone Number*

Email*

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...

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

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