CIMID HEALTH PLAN ENROLMENT FORM

CIMID Health Plan

CIMID HEALTH PLAN

Integrated preventative health care for people with chronic
illness, mental illness and disability and their families

Enrolment Form

Name

Email
Phone (bh)     Phone (ah)

Address

I am a:

Name of Organisation

Please declare your willingness to participate by ticking the box below:

I authorise the CIMID Health Plan to enter into negotiations with the
Commonwealth to develop integrated person-centred arrangements
for my health care.

In addition, please tick the options below where appropriate:

I would like to express my interest in joining the Plan's
Leadership and Governance Panel

I would like to offer my expertise in particular areas to the Plan
(please elaborate in the box below)

   I would like to be a contact for the Plan in my organisation

Tell us about your interest in this project

Any comments and suggestions?

PRIVACY STATEMENT: Details will be held in the strictest confidence and
will not be passed onto a third party.
Social Enterprise Partnerships Ltd
ABN 47108742098
PO Box 159
Yarraville Vic 3013