DOWNLOADABLE PROVIDER AGREEMENT PACKET:

In addition to the provider agreement, current and new providers must complete the Declaration of Material Assistance Form. Please follow the link below to access the DMA Form:

Declaration_of_Material_Assistance_Form_(DMA)

For further assistance or questions contact:

Julie Applegate, MA, Ohio Department of Health Consortia Coordinator HIV Care Services: 614-644-8085 / Julia.Applegate@odh.ohio.gov

Jack Lyons, BBA, Consortium 6 Care Coordinator: 330-258-0909 / Consortium_6@yahoo.com