Sheet 1: Plan Info Sheet

	
	
	
	
	
	
	
	
	
	

		
Community Outreach Monthly Event Attendance Schedule
		
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
Plan Name:
		


		


		


		


		


	
	

		


		
Contact:
		


		


		
Phone #:
		


		


		


	
	

		


		
Title:
		


		


		
Fax #:
		


		


		


	
	

		


		
Email Address:
		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		
Reporting Month:
		


		


		


		


		
Monthly Report
		


		


		


		


	
	

		


		


		


		


		


		


		


		
Amended Report
		


		


		


		


	
	

		


		


		


		


		


		


		


		
Date Filed:
		


		


	
	

		


		
Calendar Year:
		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
Pursuant to Section IV.B.4, a health plan shall submit its Community Outreach schedule 
		


		


		


		


		


		


		


		


		


		


	
	

		


		
to the Agency two weeks prior to the event.  
		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
This report is due to the Agency no later than the 20th day of the month prior to the report month.  
		


		


		


		


		


		


		


		


		


		


	
	

		


		
Amendments to a reported event is due 2 weeks prior to the event.
		


		


		


		


		


		


		


		


		


		


	
	

		


		
An amendment is necessary when there is a change in time, location, date or cancellation of the event.
		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		
Each sheet should be self explanatory.  Should you have any questions concerning the completion of
		


		


		


		


		


		


		


		


		


		


	
	

		


		
this report, please email or call the Health Plan's analyst, Bureau of Managed Health Care (BMHC).