Fillable EOI-Template-Year2 2018 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

Fill Online, Printable, Fillable, Blank EOI-Template-Year2 2018 Hepatitis C Medicaid Affinity Group: Expression of Interest Form Form

Use Fill to complete blank online HEALTH AND HUMAN SERVICES (DC) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

EOI-Template-Year2 2018 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

On average this form takes 15 minutes to complete

The EOI-Template-Year2 2018 Hepatitis C Medicaid Affinity Group: Expression of Interest Form form is 3 pages long and contains:

  • 3 signatures
  • 0 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Health and Human Services

BROWSE HEALTH AND HUMAN SERVICES (DC) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
2018 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
Overview
The Hepatitis C Medicaid Affinity Group was launched in December 2017 with the aim of
increasing the number and percentage of Medicaid beneficiaries diagnosed with hepatitis C
virus (HCV) who are successfully treated and cured. For the second year, the Affinity Group
aims to support the continued efforts of states already participating in the group, help new
state participants develop and implement their own strategies, and explore issues and
strategies related to HCV care in correctional settings. Given the correctional population
represents about one third of total U.S. HCV cases, the Affinity Group aims to encourage
collaboration between state corrections agencies, Medicaid, and public health authorities.
1
STATE: _________________________
A. Your Project and Goals
To be considered for participation, please respond to the following items and attach additional
pages as needed.
1. In the past five years, has your state Medicaid program undertaken work on HCV? If
yes, please describe efforts to date, current status, and which state partners and the
extent to which they have been involved. Optional: Please describe state efforts related
to HCV in correctional settings.
2. Briefly describe your state’s proposed strategy/ies to increase the number and
percentage of Medicaid beneficiaries diagnosed with HCV who are successfully treated
and cured. (limit length to one page). Optional: Briefly describe your state’s proposed
strategy/ies to addressing HCV in correctional settings.
3. What results does your state hope to achieve by December 2019 using the selected
strategy/ies? Please define your measures clearly.
4. Is there any specific technical assistance your state will need? If so, please describe.
1
An Overview of Hepatitis C in Prisons and Jails, National Hepatitis Corrections Network, 2016.
http://www.hcvinprison.org/resources/71-main-content/content/191-hepcprison
2019 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
5. Briefly describe the impact the opioid epidemic is having in your state.
6. Provide the current number of Medicaid enrollees in your state and the number
diagnosed with HCV infection. If available, provide the number of Medicaid enrollees
with HCV infection who have been treated or an estimate of same. Optional: Please
provide these same statistics for individuals in correctional settings.
Individuals enrolled in
Medicaid
Optional: Individuals in
correctional settings
Total number
Total number with HCV
Total treated for HCV
B. State Team
1. Please list the individuals from your state who will participate in the Hepatitis C
Medicaid Affinity Group Project in the table below.
Name Title Agency/
Department
Phone Number Email Address
2. Which of these individuals will be the lead contact for your state team?
________________________________
2019 Hepatitis C Medicaid Affinity Group:
Expression of Interest Form
C. Leadership Expression of Support
Each state team participating in the Hepatitis C Medicaid Affinity Group is expected to have the
support of the Medicaid Director or equivalent AND the State Public Health Official to
demonstrate the state’s interest in achieving the project’s goals. Please indicate the names of
the supporting officials below. In addition, if the state choses to participate in the corrections-
related activities, we encourage involvement of a correctional agency official.
Medicaid Official
Name
Signature
Title
Agency
State Public Health Official
Name
Signature
Title
Agency
Optional
Correctional Agency Official
Name
Signature
Title
Agency
The Expression of Interest form is due back to Corinna.Dan@hhs.gov on Monday,
November 19, 2018 at 5:00 PM EST.
Feder
al partners will review the Expression of Interest Form an
d select states based on the
estimated impact of their proposed strategies, demonstration of support for the project,
evaluation of local efforts, and the comp
osition of the proposed state team.
For more information about the Hepatitis C Medicaid Affinity Group go to:
htt
ps://www.hhs.gov/hepatitis/action-plan/federal-response/hepatitis-c-medicaid-affinity-
group/index.html.
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

EOI-Template-Year2 2018 Hepatitis C Medicaid Affinity Group: Expression of Interest Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document