Key Contact Program | Registration Form

Key Contact Program | Submission Form
The MDAFP Key Contact Program is a strategic grassroots advocacy program designed to help the MDAFP build strong, on-going relationships with legislators across the state.
MDAFP Member?*

YesNo
PERSONAL INFORMATION:
Name*

First NameLast Name
Designation:
MD, DO, FAAFP, etc.
Organization/Clinic*
CONTACT INFORMATION:
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address:*
example@example.com
Phone Number*

Area CodePhone Number
Legislators You Know

In the spaces below, please list the state legislators you know personally and select the box that best describes your relationship.
Representative/Senator
How do you know this individual?

SociallyNeighborRelativeProfessionallyPatient
Representative/Senator
How do you know this individual?

SociallyNeighborRelativeProfessionallyPatient
Representative/Senator
How do you know this individual?

SociallyNeighborRelativeProfessionallyPatient
Representative/Senator
How do you know this individual?

SociallyNeighborRelativeProfessionallyPatient
Representative/Senator
How do you know this individual?

SociallyNeighborRelativeProfessionallyPatient
I would be willing to testify at the legislative committee hearings on the following issues:

Workforce Development/Pipeline IssuesTelehealthHealth EquityPrior Authorization/Step TherapyLoan Assistance Repayment Program for Physicians (LARP)Medicaid ReimbursementPrimary Care InvestmentPublic Health Issues
AAFP ID#:
Should be Empty: