Agency Name
(Required)
Name
(Required)
First
Last
Pronouns
(Required)
Email
(Required)
Phone
(Required)
Role at Agency (Check All that Apply)
(Required)
Executive Director/CEO
Component Director (Head of Program)
Data Contact
Financial Contact
Clinical Supervisor (RCC only)
EIM Access Administrator
ERAP Primary Contact
Other Contact
If you selected “Other Contact”, please specify
(Required)
Should DPH remove the current contact information on file for the role(s) selected at your organization?
(Required)
Yes, they are no longer in the role(s)
No, there are two people in the role(s)
Yes, but not for all roles selected
Not sure
If you selected “Yes, but not for all roles selected”, please describe the necessary changes to the existing contact information.
(Required)