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* 1. Name of organization

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* 2. Please indicate your interest in the Brightpoint Care Social Care Network:

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* 3. Name

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* 4. Phone 

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* 6. Physical Address

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* 7. Multiple service delivery locations: please list below

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* 8. Website

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* 9. Please provide your Federal Employee ID Number (EIN)

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* 10. Please select all locations where organization provides service

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* 11. Does your organization serve any of the following populations?

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* 12. Service capacity: select all services your organization provides, please see RFA for full description

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* 13. In what languages does your organization provide services (check all that apply):

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* 14. Please share any other information that would be useful to know about the organization

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* 15. Does your organization provide care management services under the Medicaid Health Home program?

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* 16. How many Medicaid members did your organization serve in 2023?

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