Form Name	Format*
Intensive Technical Assistance Request Form (instructions)
Health Care Representative Form
Individualized Feeding Plan Form
Lifetime Medical History Form

To Use Intensive TA Request Form

Fill out form and send by e-mail:

Click on MS Word version of the form.

You will see the following dialog box:

Click on Save to save the document to your computer.

Fill-out required information.

Save completed document to your computer.

To e-mail, click on File, then Send To, then Mail Recipeint (as attachment)

Send to info@hcqu.org

 

Print form and send by fax or mail:

Click on PDF version of form. You will see the following dialog box:

Click on Open.

Print Form and complete by hand.

Fax to (724) 283-1012 OR

Mail to:

Community Health Connections

120 Hollywood Drive, Suite 201

Butler PA 16001