Please fill in form and submit.

Thank you!!!!

Andrea Flores, MPH - aflores@ccchd.com

Clark County Combined Health District

Please share this form with others who may have input for the Resource Guide.

Any questions may be directed to me at (937)390-5600 x280.

Fax inquiries may be sent to (937)390-5626 Attn: Andrea

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* 1. Describe the Service offered:

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* 2. How should the Public Access this Service?

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* 3. Agency Name

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* 4. Agency Adress

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* 5. Agency Phone

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* 6. Is there a specific contact person for this service?

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* 7. Is there a cost for the service? If so, describe the cost. Is there a sliding fee scale? Is Medicaid or other insurances accepted? Is it cash only? Does this fee change often?

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* 8. Is there a Sponsor or Grantor that should be mentioned in the publicity for this service?

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* 9. What other info/notes should be included about this service?

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* 10. Name of person who is submitting this form:

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* 11. Your contact info in case we have questions 

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