OHA Outreach Form

NOTICE: The Office of the Healthcare Advocate is currently closed to public visitors as a protective measure for the safety of customers and staff. We will continue to provide services by email and telephone. The Office of the Healthcare Advocate may be contacted by utilizing our on-line services on our website, by calling our main number at 1-866-466-4446 or by emailing us at healthcare.advocate@ct.gov

OHA Outreach Presentation & Materials Request Form

Date

This request is for:

Presentation Materials Request Contact Name Client Organization/Company Name Work Phone Cell Phone Email Address City State ZIP Code Presentation topics to be addressed: Anticipated number of attendees?

Date/Time of Presentation

Date of Presentation Time of Presentation

If materials requested specify how many of each:

Brochures Posters

Other/Special Requests Referred by

Connecticut State Office of the Healthcare Advocate

OHA Outreach Presentation & Materials Request Form

This request is for:

Date/Time of Presentation

If materials requested specify how many of each: