Clone of Course Registration Form

Medicaid OTC Benefit Education Registration Form

Fill out the form for registration
Medicaid OTC (over-the-counter) benefits allow eligible members to receive a set dollar amount to purchase health and wellness products. The specific benefit amount, how it can be used, and the products covered will be discussed at this event.
Client Name

First NameMiddle NameLast Name
E-mail
example@example.com
Mobile Number
Emergency Contact
Additional Comments
Should be Empty:

Medicaid OTC Benefit Education Registration Form