Mississippi Medicaid Beneficiary Advisory Council Nomination Form

The MS Medicaid Beneficiary Advisory Council is a group of individuals who are currently or have been Medicaid beneficiaries and individuals with direct experience supporting Medicaid beneficiaries who will advise the State regarding their experience with the Medicaid program on matters related to policy development and matters related to the effective administration of the Medicaid program.

I am*

Applying to be a council member

Nominating someone to be a council member

Nominators Name*

Nominators Phone #*

Phone

Nominee First Name*

Nominee Last Name*

Nominee Street Address*

Nominee Mailing Address if different

Nominee city*

Nominee zip code*

Nominee Phone #*

Phone

Nominee Email*

I am a current or former:*

Please check the option that best describes you. If multiple options apply, please explain in the upcoming other information section.

Medicaid recipient

family member and/or caregiver of a Medicaid recipient

person associated with consumer or patient advocacy groups

Medicaid Recipient First Name

Medicaid Recipient Last Name

Recipient Medicaid ID

Recipient DOB

Nominee represents the following group(s)*

Select all that apply

families with children

persons receiving behavioral health services

persons receiving home and community-based services

persons receiving institutional long term care services

persons associated with consumer or patient advocacy groups

persons associated with a tribe or tribal community

persons who live in rural or frontier areas

Other Information

Name of Advocacy Group(s)*

What experience or skills do you have that would be a benefit to the committee?*

Please describe any professional or lived experience demonstrating your qualifications for the council.

Serving on this Council requires a two-year term that includes a minimum of four quarterly meetings each year.*

By selecting your choice below, you understand the importance of your participation and the expectations set forth for this commitment.

I am able to make this commitment

I am NOT able to make this commitment

Send me a copy of my responses

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