• Beneficiary Advisory Committee Application

  • Thank you for applying to be on the Vermont Medicaid Beneficiary Advisory Committee (BAC). The Committee gives advice about Medicaid to the Department of Vermont Health Access (DVHA). We want people who are or have been on Medicaid or their families or caregivers.

    • It is okay if this is your first time on this kind of committee.
    • We can help you learn about healthcare in Vermont.

    Committee members may get paid for the cost of coming to meetings. This can be $50 for each meeting you attend. We can also pay for a personal assistant, travel and child care costs, if needed. We can pay for other help you need to be on the committee.

  • Format: (000) 000-0000.
  • Check all the answers that are true for you:*
  • Check all the times you can come to meetings Monday through Friday.*

  • Optional Information

    Help us learn more about you and your experiences with Medicaid. Write as much or as little as you want.

  • I certify that the information provided in this application is true, correct, and complete to the best of my knowledge.

  • Date Signed
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: