Form CMS-10606 Speaker Request Form

12/31/2015

Speaker Request Form – Health Care Payment Learning & Action Network

Speaker Request Form

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Home (http://hcplan.wpengine.com) / Get Involved (http://hcplan.wpengine.com/get-involved/) / Speaker Request Form

Speaker Request Form
Speaker Request Details

Tags
Consumers & Patients (http://hcplan.wpengine.com/tag/consumerspatients/)

Name of Requested Speaker

(optional)

Event Type *
Annual Meeting
Event Name *

Event Website
http://



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Event
Date *

Speaker Request Form – Health Care Payment Learning & Action Network

Approximate
Speaking
Time *

HH

:

MM

AM
Please
include
approximate
time on the
agenda you
are
requesting
representative
to speak

Event Location *
In-Person
Event Address

Street Address

Address Line 2

City

State

ZIP Code

Audience Profile

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Speaker Request Form – Health Care Payment Learning & Action Network

Describe the target audience for this
event (i.e., Industry, Academia, Patient
Groups, Advocacy Groups, Business
Executives)

Speech Topic *

Speech Format *
Keynote Address
Speech Topic Details

Include in your request: Length of
Speech time, Length of Q&A Time, Who
will Introduce the Speaker, Anyone the
Speaker should Recognize or Thank, Link
to agenda, and other details that would
be helpful

Requested Speaker Materials

Outline information requested of the
speaker including: PowerPoint
Presentation, Bio, Headshot, etc.

Event Set-up

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Speaker Request Form – Health Care Payment Learning & Action Network

If known, please provide details on event
set-up including if there will be a
podium, if A/V (e.g. computer,
microphone) will be provided, room setup (e.g. classroom, rounds), expected
number of participants for presentation

Speaker Logistics

Provide any details know about speaker
participation in event including: How
early should speaker arrive? Is there a
speaker ready room? Will the speaker be
served food? Is there an admission
charge for speakers and how much? Can
or should speaker participate in other
parts of the event?

Media Information

Is this event open to the media? Will
there be a request for the speaker to
address the media before or after the
event?

Organization Information

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12/31/2015

Speaker Request Form – Health Care Payment Learning & Action Network

Name of Organization *

Organization Website *
http://

Organization's Point of Contact
(POC)
Point of Contact for Speaker Request

POC Name *

POC Title

POC Phone Number(s)

POC Email *

Submit

Our Mission

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Speaker Request Form – Health Care Payment Learning & Action Network

To accelerate the health care system's transition to alternative payment models by combining the innovation,
power, and reach of the public and private sectors.

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Upcoming Events

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Speaker Request Form – Health Care Payment Learning & Action Network

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