Outreach Form

Please complete this form to record contact information for individuals reached during an FHJP outreach event. Before submitting, confirm that the individual has agreed to provide their information and indicated whether they would like legal assistance or receive the FHJP newsletter.





    Enter numbers only, including the area code.



    Do they need legal help concerning Medicaid or another public health program? *

    Do they want to receive the FHJP newsletter? *


    Please confirm that the individual agreed to provide this information before submitting the form.

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