Members – Communities Together for Health Equity (CTHE)

1. What is the name of your Agency?*

Agency's Name

2. Contact Full Name*

Name

3. Contact Title*

Title

4. Contact Email Address*

Email Address

5. Contact Phone Number*

Phone

6. Does your agency have a 501(c)3?*

Yes

7. Does your agency have at least 3 years of experience in either: (1) Working with Medicaid eligible/enrolled individuals in need of services related to Social Determinants of Health (SDH) (2) Past regional collaboration with other agencies in NYC on other SDH- or health care-related projects or programs*

Yes

8. Is your annual operating budget less than or equal to $5 million?*

Yes

9. Does your organization bill Medicaid now or plan to start billing Medicaid within the near future?*

Yes

10. In which Borough does your organization provide services? Please check all that apply.*

Bronx

Brooklyn

Manhattan

Queens

Staten Island

Name of Agency

First Name

Last Name

Email Address

Phone

Event Name*

Write Here

Start Date/ Time*

Select Start Date & Time ×

End Date/ Time*

Select End Date & Time ×

Does this event require registration?*

Yes

Registration Link

Write Here

Venue Address*

Name of Venue

Address

City

State

Postal Code

Organizer's First Name*

Name

Organizer's Last Name*

Name

Organizer's Phone Number*

Phone

Organizer's Email Address*

Email Address

Organizer's Web Address

Write Here

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