2009-10 Healthy Benefits Matching Screening Grant Form

CIS Healthy Benefits program is again offering a 2009-10 Matching Screening Grant program. This grant is available to any employer member of a CIS medical plan.

1. General Information
Entity Name:  
Screening Coordinator Name:  
Address:  
City:  
Zip:    
Phone:  
Email:    

2. Screening Provider Information
Provider Company:  
Name of Primary Contact for Provider:  
Provider Address:  
Provider City:  
Provider State:
Provider Zip:    
Provider Phone:  
4. Participating Employees
   Number of Total Participants:   
Attach Word or PDF copies of:
1) Screening invoice:  
2) Screening participation list