Member Advisory Committee Representative Application Form

Please complete the application form below for being a Member Representative for the Virginia Premier Member Advisory Committee (MAC).

Member Representatives will receive an invite to all MAC meetings with attendance instructions. Meetings are held online. You may attend from a computer or mobile device. If you do not have internet access, you may call the phone number we will provide. The meeting schedule is posted on VirginiaPremier.com/mac.

If you have any questions, please call the Member Outreach Team at 1-877-719-7358 (TTY: 711).

Thank you for your interest in being a Member Representative!

I attest that I am at least 18 years old at the time of this application.

Additionally, in consideration of my application, I attest and agree to the following:

I agree to keep any information learned through this process, including the Member Advisory Committee meetings, as confidential.
I may provide my input, comments, suggestions, and ideas (collectively, “Feedback”) during this process, including during the Member Advisory Committee meetings. Virginia Premier Health Plan is entitled to use such Feedback for any purpose without notice, restriction or remuneration of any kind to me.

If selected, I agree to serve as a Member Representative for the Virginia Premier Member Advisory Committee (MAC).

I know that I will serve as a Member Representative for 1 year, starting January 1, 2023 and ending December 31, 2023.

I agree to the expectations listed below:

Serve a 1-year term as a Member Representative for MAC Meetings
Strive to attend all meetings necessary for the success of the program
Speak in support of all members at MAC meetings
Share your feedback and suggestions about the health plan
Take a brief survey at the end of each meeting

If you are not able to adhere to the terms of this agreement, please contact the Member Outreach Team at 1-877-719-7358 (TTY: 711) or email memberoutreach@virginiapremier.com.

Form

Your Information

Note: Asterisk * indicates a required field

First Name*

Last Name*

Address 1*

Address 2:

City*

State*

ZIP Code*

Email Address*

Phone*

Is this a mobile phone number?* Yes No

Medicaid Plan Type*

Medicaid ID Number

Preferred language*

Will you need accommodations?*

Preferred method of communication (select all that apply) Mail Call Email Text Message

By accepting and typing my name below, I agree to the terms of this registration form. If participant is a minor, the minor's legal custodian must read and accept on behalf of the minor. I agree*

Electronic Signature*

Date: May 11, 2025

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