Page 1 of 1

hey MiCHWA!

For any questions and concerns related to the medicaid registry please visit:  MI Medicaid CHW Registry Support Request Form

I'm am...

What's your name?

What is your email?

What is your mobile number?

What is your instagram handle?

What organization are you with?

Which cohort are you currently teaching?

When did you graduate?

Who was/is your instructor?

What can we help you with?

If this is a data request, provide the specific field names you need in the sheet we share back to you.

Please share your anonymous feedback below.

Can we contact you with updates via SMS or email?

Can we contact you with updates via SMS or email?