Fillable Stakeholder Workgroup Nomination Form (Commonwealth of Massachusetts)

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Stakeholder Workgroup Nomination Form (Commonwealth of Massachusetts)

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NOMINATION FORM for
Stakeholder Work Groups for MassHealth Restructuring and Payment Reform
July 2015
The Executive Office of Health and Human Services (EOHHS) is seeking individuals to serve on eight work
groups to inform the restructuring of the MassHealth program and the development of at-scale
payment reforms.
ABOUT YOURSELF
Name:
Job Title (if applicable):
Organization (if applicable):
Street Address:
City, State, Zip Code:
Telephone:
Email:
Preferred method of communication:
WORK GROUP SELECTION (check off the work group or work groups for which you are nominating
yourself. )
Strategic Design
Attribution
Payment Model Design
Certification Criteria
Health Homes
Quality Improvement
LTSS Payment Models
BH Payment Models
Note: In order ot achieve appropriate representation in each work group, EOHHS may, in its sole
judgment, invite nominees to participate in work groups other than the one(s) for which they are
nominated.
QUALIFICATIONS (please answer for each work group checked off above)
Interest in Participating: Why do you want to serve on the work group(s)?
Print
Clear
Kno
wledge/Skills/Experience: List three qualities that you have that will help the work group(s)
achieve its/their goals.
R
epresentation and Affiliations: Please describe your affiliations with any stakeholder organizations
or your relationship with MassHealth.
S
UBMISSION INSTRUCTIONS
Return a complete copy of this nomination form by e-mail, mail, or fax to:
E-mail: Melissa.Morrison@s
tate.ma.us
Mail: Executive Office of Health and Human Services
A
ttn: Melissa Morrison
One Ashburton Place, 11
th
Floor
Boston, MA 02108
Office Phone: (617) 573-1611 Fax: (617) 573-1893
Please put “Stakeholder Work Group Nomination Form” in the subject line of your e-mail or fax
or on the envelope if submitting by mail.
Nominations are due no later than Wednesday, August 5, 2015, at 5:00 PM.
Public Records Notice: In submitting this nomination form, you understand that any information
contained within in it, including voluntary self-identification as a recipient of MassHealth or
Medicare coverage, may be made public. All responses and information submitted in response to
this nomination form are subject to the Massachusetts Public Records Law, M.G.L. c. 66, § 10, and
M.G.L. c. 4, § 7, subsection 26.
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Stakeholder Workgroup Nomination Form (Commonwealth of Massachusetts)

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Completed 26 July 2020

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