ADVOCACY ASSISTANCE REQUEST FORM

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This form is used to decide if we can help you but is not a guarantee.

If you would like someone from the Individual Advocacy Team to get in touch with you about your problem, please give us the following information.

We want to help you understand confusing Medicaid Notices. To assist us please please have your full notice ready to send to the CCDC Medicaid advocate when they contact you.

If you have not been contacted by an advocate within three business days, please email Hillary Jorgensen at hjorgensen@ccdconline.org.

Email *

First Name *

Last Name *

Phone Number *

Email Address (If you don't have an email account, write N/A.) *

Date of birth? *

YYYY

Race? *

Asian

African American

Hispanic

White/Caucasian

Native American

Other:

Gender? *

Female

Male

Non-binary

Transgender

Other:

Are you homeless?

Yes

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