MassHealth Pop Up 2 Registration Form

MassHealth Event Registration Form

Thank you for your interest in attending the MassHealth SWI Pop Up event "Lessons from Other States: Creating Care Delivery Systems that Recognize and Respond to Member Priorities and Circumstances." The event will occur on Friday December 6, 2019, from 10:00 am to 12:30 pm ET at the Roxbury Innovation Center (2300 Washington St, Boston, MA). Please complete this form to confirm your registration.

Additional details on registration, parking, and transportation coming soon.

Note: this registration form must be completed by each individual who would like to attend the event.

1. First Name *This question is required.

2. Last Name *This question is required.

3. Organization *This question is required.

4. What type of organization is this? *This question is required.

5. Role *This question is required.

6. Please provide the names of any ACO(s) and/or CP(s) with which you are affiliated.

Please provide your preferred title

8. Email Address *This question is required. This question requires a valid email address.

9. Please provide information regarding any accommodations that you require (e.g., food allergy or mobility limitations)

10. Do you plan to drive to this event?