Meeting Request

Please complete and submit the form below to request a meeting with the Department. Your submission will be reviewed and you will be contacted by a representative of the Department
Request Date:  
Your Organization: 
Sponsoring Organization:   Type of Organization:  
Contact Name:   Contact Phone:  
Contact E-mail:     Website:   
Meeting Request Information:  
Purpose of Meeting:   Amount of time needed for meeting:  
Meeting date preference/time frames:   Individual or Individuals with whom you are requesting a meeting:  
Will you have any special needs or requirements, including A/V needs?   Additional Information? 

Please type the confirmation code in the picture below into the text box.






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Need Help with Your Health Plan?

Call the DMHC Help Center

1-888-466-2219

or submit an Independent Medical Review/Complaint Form