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SHIBA speaker request form

To request a speaker, fill out this form and select the Submit button.

Your contact information

Organization:
Contact name:
Phone:
Fax:
Email:

Presentation type

Select one of the following speaker presentations:
Information about SHIBA
How to get ready for Medicare
Information about Medicare Part D
Preventive care benefits
Health care coverage for kids
Understanding your health care coverage options
How to fight health care fraud and abuse
Long-term care overview

Event information

Name of event:
Date: (mo/day/yr)
Location: (city)
Length of event: (hrs, mins)
Panel discussion: (yes/no)
# of attendees: (approximate)

Equipment needs
Overhead projector: (yes/no)
projector: (yes/no)
Screen: (yes/no)
Microphone: (yes/no)
Podium: (yes/no)
Other equipment:

Comments:


Questions?

Call: 1-800-562-6900
Email: SHIBAHelpLine@oic.wa.gov