Aetna Better Health Advocate Advisory Council

[Guest guest]

?Here is an application for the Aetna Better Health Advocate Advisory Council

for anyone interested.

Ellen

Advocate Advisory Council Membership Application Form

The Aetna Better Health Advocate Advisory Council gives you a place to talk to

other advocates and community stakeholders and Aetna Better Health staff. The

Advocate Advisory Council gives you the chance to provide input about the

program, its operations and ways to improve its quality and value to members.

All interested in applying for the Aetna Better Health Advocate Advisory Council

should complete this form and return it to:

Aetna Better Health

One South Wacker Drive, 12th Floor

Attn: Hall

Mail Stop F646

Chicago, IL 60606

Fax: 1-855-802-4291

E-mail: aetnabetterhealthillinois@...

PLEASE TYPE OR PRINT CLEARLY.

FIRST NAME MI LAST NAME

ORGANIZATION/EMPLOYER (IF APPLICABLE)

TELEPHONE E-MAIL ADDRESS

PHYSICAL ADDRESS

CITY ILLINOIS ZIP COUNTY

1) Please tell us about yourself. Please write about your background and

participation in other advisory councils. Attach more pages if needed.

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2) Please tell us why you want to be on this council. What will your background

or interests offer to the team? Limit to one to two paragraphs please. Attach

more pages if needed.

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CONTINUED ON REVERSE

IL-10-10-18

3) Are you currently a member of other Medicaid or advocacy committees or

councils? No Yes (please list):Attach more pages if needed.

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Race/ethnicity (optional): Experience with Medicaid:

American Indiana/Alaska Native None

Asian/Pacific Islander Less than 1 year

Black 1-2 years

Hispanic 3-5 years

White More than 5 years

Other More than 10 years

What is your membership category (check all that apply):

Member - you are currently enrolled in Illinois Medicaid

Member of Aetna Better Health

Other Medicaid Program - Please list:

Family member or legal guardian of a member. Name of member

Community organization. Name of community organization

Advocate

Can you attend daytime meetings?

Yes - any time Yes - morning only Yes - afternoon only No

We will provide transportation to these meetings. Do you need transportation or

any special accommodations? If so, what?

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I certify that the statements made by me on this form are true and correct to

the best of my knowledge and belief. I agree to serve on the Aetna Better Health

Advocate Advisory Council for two years. I will attend and participate in four

meetings a year and any other sub-committee meetings as needed. If I am unable

to attend, I will notify the Aetna Better Health Member Services Manager prior

to the meeting.

SIGNATURE OF APPLICANT DATE

Completion of this form does not make someone a council member. Aetna Better

Health will choose members based on geographic diversity and representation of

other Medicaid members.

IL-10-10-18

Ellen Garber Bronfeld

egskb@...