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Commitee name(*)
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Health Division(*)
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If other, please specify:
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As our Consumer Representatives Program is currently running close to capacity, HCCA has identified the following priority areas. Please select which of these areas are relevant to your committee. Please note: if your committee falls outside of these areas, HCCA will still process your request.(*)
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What role will the consumer representative have on the committee? (*)
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If other, please specify: (*)
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Meeting Venue(*)
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Next Scheduled Committee Meeting(*)
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Meeting frequency (*)
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Meeting time(*)
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Number of Consumer Representatives Requested(*)
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Terms of Reference(*)
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Committee contact person(*)
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Position(*)
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Postal address(*)
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Phone number(*)
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Fax(*)
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Email address(*)
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Reimbursement Policy(*)
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Please ensure all fields are completed before submitting your request. We cannot begin our processes to endorse an appropriate consumer representative without all of this information.