DATE:             Interested Parties

TO:                  AHCCCS Administration

FROM:            March 18, 2015

SUBJECT:      Nomination Process for the State Medicaid Advisory Committee

The State Medicaid Advisory Committee (SMAC) reviews and advises AHCCCS on the operations, programs, and planning for Arizona's Medicaid program. On January 20, 2015, Arizona’s SMAC voted to amend its bylaws to increase the SMAC membership adding three additional positions - two new positions designated for representatives of AHCCCS recipients, family members of an AHCCCS recipient, or a community-based organization and one new position designated to represent a provider or professional organization.

Nominations can be submitted by completing and submitting the attached Nomination Form. The nomination process will be open for 60 days through  May 18, 2015.  Appointments will be made by the AHCCCS Director and announced when the positions are filled.

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov

STATE MEDICAID ADVISORY COMMITTEE
(SMAC) Nomination Form

Your Name:	
	
Nominee’s Name:	
Address:	City/State:	Zip Code:	
Employer:	Position/Title:	
Office Phone Number:	Fax:	
E-Mail Address:	
Category (mark one):

 	Public Member (recipient, family member, advocate)

 	 Provider/Professional (hospital, FQHC, doctor/nurse, association)	
	
What experience or skills does the nominee have that would be a benefit to the committee?	
Please complete all fields. Mail, Fax, or E-Mail to: AHCCCS, Office of the Director
801 E. Jefferson St., MD 4100
Phoenix, AZ 85034
Phone: (602) 417-4711
Fax: (602) 256-6756
E-Mail: theresa.gonzales@azahcccs.gov	

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix, AZ 85002 • 602-417-4000 • www.azahcccs.gov