MANAGED LONG TERM CARE DEMONSTRATION PROGRAM
REPLY FORM -- PLEASE RESPOND BY November 4, 2005.

Mail to: Assembly Health Committee, Room 822 LOB, Albany, NY 12248
Or fax to: 518-455-5939
box I plan to testify at the November 10, 2005 hearing on Managed Long Term Care Plans

box I plan to attend, but not testify at the November 10, 2005 hearing on Managed Long Term Care Plans

box

I will require assistance and/or handicapped accessibility information. Please specify type of assistance required:




NAME:

TITLE:

ORGANIZATION:

ADDRESS:

CITY/STATE/ZIP:

TELEPHONE:

FAX TELEPHONE:

E-MAIL:
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