attachment 02112011 rev date.docx

DOCX document 14 KB Posted

Attached to
Medicaid Incentives for Prevention of Chronic Diseases (MIPCD)
Opportunity number
CMS-1B1-11-001
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Notice of Intent to Apply

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ATTACHMENT

Notice of Intent to Apply

Submission:

· By Facsimile - Preferred Fax: 410-786-9004

· By PDF file of the “Intent to Apply” to Jeffrey.Clopein@cms.hhs.gov.

Please complete and return by April 4, 2011 to:

Jeffrey Clopein Centers for Medicare & Medicaid Services 7500 Security Boulevard Mail Stop S2-16-06 Baltimore, MD 21244-1850 Phone: 410-786-7252, Fax: 410-786-9004

1. Name of State:

2. Applicant Agency/Organization:

3. Contact Name and Title:

4. Address:

5. Phone: Fax:

6. E-mail address:

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