Application for MaineCare CHW Consultants

Any CHW that wishes to serve as a MaineCare consultant should complete this application. MCD Global will select individuals to serve as consultants who best represent Maine’s rural, ethnic, geographic, and economic reach. For assistance, please contact benjamin.hummel@maine.gov.

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* 1. Full Name

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* 2. Phone Number

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* 3. Email Address

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* 4. Organization

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* 5. Are you committed to serving as a MaineCare consultant?

Yes

No

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* 6. Briefly describe your current or prior experience as a CHW, including the communities you serve (rural, ethnic, geographic, economic):

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* 7. What do you hope to gain from this opportunity?

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* 8. Do you work within or in partnership with a clinic or health system (not required)?

Yes

No

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* 9. Do you supervise or manage a CHW program (not required)?

Yes

No

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* 10. Please share what are the best days/times for meetings: