Consumer Representative Request Form
  1. Commitee name(*)
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  2. Health Division(*)
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  3. If other, please specify:
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  4. 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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  5. What role will the consumer representative have on the committee? (*)





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  6. If other, please specify: (*)
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  7. Meeting Venue(*)
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  8. Next Scheduled Committee Meeting(*)

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  9. Meeting frequency (*)
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  10. Meeting time(*)
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  11. Number of Consumer Representatives Requested(*)
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  12. Terms of Reference(*)
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  13. Committee contact person(*)
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  14. Position(*)
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  15. Postal address(*)
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  16. Phone number(*)
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  17. Fax(*)
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  18. Email address(*)
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  19. Reimbursement Policy(*)
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  20. 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.