Speaker/Event Request

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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.

Required fields are identified with a *

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?

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Documents & Links

Need Help? Call the DMHC Help Center at
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Gavin Newsom

California Governor

Mark Ghaly

Secretary, Health and Human Services Agency

Shelley Rouillard

Director, Department of Managed Health Care