Self Paced Packets Request

Subsidy Billing/Electronic Attendance

Self-Paced Packet Request Form
Email
example@example.com
Stars Id Number
Provider Name

First NameLast Name
Address to Mail the Packet (PO Boxes are fine)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Requested Packet Language
Provider Type
Self-paced Packet Requested (Choose all that apply)
To schedule a live Electronic Attendance session please click the link below:

FFN: https://imaginewa.org/eas-ffn/

LFCCP/CCC: https://imaginewa.org/eas-lfccp/
Requester's Name (If you are requesting on someone else's behalf)

First NameLast Name
Would you like your packet emailed or mailed to your address?
Do you have a printer or access to a printer to complete this form?
Requester's Email
example@example.com
Should be Empty:

Subsidy Billing/Electronic Attendance