Texas Department of Insurance

Speakers Bureau Request Form Texas Consumer Health Assistance Program

To request a presentation, please provide the following information: REQUESTOR INFORMATION Organization: Your name: Phone number: E-mail address: Mailing address: Date of event: Second choice date: Estimated number of attendees: Do you expect media coverage? Y/N: Location of event: EVENT INFORMATION Time:

Statewide event? No Yes Do you need a bilingual speaker or interpreter for the hearing impaired? Please specify: __________________________________________________ Name of speaker requested: __________________________________________________ Please indicate the topic of the event/presentation: Texas CHAP Topics (please check all that apply) Federal health reform general overview Rescission Pre-existing condition exclusion for children Dependent coverage to age 26 Pre-existing Condition Insurance Plan Prevention Services Annual benefit maximum Lifetime benefit maximum Please return this form to: Fax: 512-305-7463 E-mail: TDISpeakersBureau@tdi.state.tx.us Mail: Texas Department of Insurance Public Education, MC 111-1A P.O. Box 149104 Austin, TX 78714-9104 Additional information call: Melissa Hield, 512-322-4349
E-mail Addresses: Under most circumstances, individual e-mail addresses are protected by the Texas Public Information Act. Sharing this information for purposes of processing your information does not waive these confidentiality protections. However, you may affirmatively consent to release of your e-mail address in response to a public information request or inquiry. If you would like more information about the public or confidential nature of information maintained by TDI, please consult our Open Records Policy and our Website Privacy Policy on our website. Access and Correction of Personal Information: With few exceptions, you are entitled to information that the Texas Department of Insurance (TDI) collects about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies of information about yourself, including private information. However, TDI may withhold information for reasons other than to protect your right to privacy. Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about the procedure for correcting information kept by TDI, please email the AgencyCounsel@tdi.state.tx.us of TDIs Legal & Compliance Division or contact them by phone at (512) 475-1757 or review TDIs Corrections Procedure on our website.

No

Primary occupation/composition of audience (ex: employers, injured workers, insurance consumers, health care providers, insurance industry, government, public): ________________________________________________

Appeals and grievances Premium rate increases Medical loss ratio rebates Discrimination based on salary Out of network emergency care Choice of primary care/pediatricians Access to OB/GYN Early Retiree Reinsurance

December 2010