Speaker/Event Request Form

Please complete and submit the form below to request a speaker or Department representative to attend your upcoming event. 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:   
Your Program:  
Date of Program:   Time of Program:  
Name of Program:   Theme/Purpose of Program:  
Location of Program:   Proposed Topic:  
Presentation Format (Panel, Speech, Roundtable, Tabling, Etc.):   Length of Speaker’s Presentation:  
Your Audience Composition:  
Size of Audience:   Language needs?  
Audience Composition (consumers, stakeholders, providers, etc.):   Additional Information? 

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

Confirmation Code




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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