Provider Fair Application

The purpose of the Provider Fair is to better understand the vast array of options that are available for our Service Coordinators to support our members outcomes.  We appreciate your interest.  On a quarterly basis we will hold small informational fairs at each of our CCCW office locations within our region.   Approximately eight providers will give a short (5 minute) presentation.  After presentations staff will visit with you at your booth.  We will make this booth interaction available for at least two hours, affording staff an opportunity to visit with you as they are able.  We are confident this will provide an excellent communication opportunity for both providers and staff.

Please complete the following application.  Contracted providers will be selected based on opportunity to expand member choice/options.  Your acceptance will be confirmed and arrangements made for booth accommodations (electrical outlets, etc.).

Thank you,

CCCW Provider Outreach Workgroup

Locations / Dates Available:
Stevens Point - July 9, 2010 - 9:00 am - 11:00 am
Stevens Point - October 8, 2010 - 9:00 am - 11:00 am
Wausau - July 9, 2010 - 1:00 pm - 3:00 pm
Wausau - October 8, 2010 - 1:00 pm – 3:00 pm
Wisconsin Rapids - August 13, 2010 - 1:00 pm - 3:00 pm
Wisconsin Rapids- November 12, 2010 - 9:00 am - 11:00 am
Marshfield- August 13, 2010 - 1:00 pm - 3:00 pm
Marshfield- November 12, 2010 - 1:00 pm - 3:00 pm
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Company Name:
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Area of Specialty:
People with Physical Disabilities
People with Development Disabilities
Elderly
People with Mental Health Illness
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Do you currently have a contract with CCCW?:
Yes
No-If interested in contracting with CCCW, please contact Emmy Lou Eron, PN Specialist at 715-204-1770.
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Number of members served?:
0-10
11-25
26-50
51-75
76 and up
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Purpose of attending?:
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Contact Name:
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Phone Number:
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Contact Email:

Additonal comments or questions?:

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