Material Request Form

We are offering delivery of information about our community safety net for the uninsured or enrollment training (currently virtual) for any staff or volunteers. Please fill out the form below and we will contact you to arrange delivery or training.

About our Organization or Location

Name

Company

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

Phone Number

Area CodePhone Number

We are interested in having information about Ingham Health Plan available for our community

YesNo

We are interested in enrollment training

YesNo

Other comments

What is the design meant for?