MANDATORY MANAGED CARE FOR SSI BENEFICIARIES
REPLY FORM -- PLEASE RESPOND BY JANUARY 19, 2006.

Mail or fax to: Assembly Health Committee, Room 822 LOB, Albany, NY 12248; fax: 518-455-5939

[    ]   I plan to testify at the January 26, 2006 hearing on Mandatory Managed Care for SSI beneficiaries.

[    ]   I plan to attend, but not testify.

[    ]   I require assistance and/or handicapped accessibility information. Type of assistance required:



NAME:

TITLE:

ORGANIZATION:

ADDRESS:

E-MAIL:

TELEPHONE:

FAX TELEPHONE:

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