PUBLIC HEARING REPLY FORM

Persons wishing to present testimony at the public hearing on Medicaid Managed Care Prescription Drug Carve-In Implementation are requested to complete this reply form as soon as possible and mail, email or fax it to:

EstÝbaliz Alonso
Senior Legislative Analyst
Assembly Committee on Health
Room 520 - Capitol
Albany, New York 12248
Email: alonsoe@assembly.state.ny.us
Phone: (518) 455-4371
Fax: (518) 455-4693
box
I plan to attend the following public hearing on Medicaid Managed Care Prescription Drug Carve-In Implementation to be conducted by the Assembly Committee on Health on December 19, 2011.
box
I plan to make a public statement at the hearing. My statement will be limited to 10 minutes, and I will answer any questions which may arise. I will provide 10 copies of my prepared statement.
box
I will address my remarks to the following subjects:




box
I do not plan to attend the above hearing.
box
I would like to be added to the Committees' mailing list for notices and reports.
box
I would like to be removed from the Committees' mailing list.
box
I will require assistance and/or handicapped accessibility information. Please specify the type of assistance required:




NAME:


TITLE:


ORGANIZATION:


ADDRESS:


E-MAIL:


TELEPHONE:


FAX TELEPHONE: