Resource Collection Form for the Diabetes Resource Guide Please fill in form and submit.Thank you!!!!Andrea Flores, MPH - aflores@ccchd.comClark County Combined Health DistrictPlease 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 OK Question Title * 1. Describe the Service offered: OK Question Title * 2. How should the Public Access this Service? OK Question Title * 3. Agency Name OK Question Title * 4. Agency Adress OK Question Title * 5. Agency Phone OK Question Title * 6. Is there a specific contact person for this service? OK Question Title * 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? OK Question Title * 8. Is there a Sponsor or Grantor that should be mentioned in the publicity for this service? OK Question Title * 9. What other info/notes should be included about this service? OK Question Title * 10. Name of person who is submitting this form: OK Question Title * 11. Your contact info in case we have questions OK DONE