Marketing Event Reporting Form - NHRMC Health Advantage

MCE ID*
Contract Number*
Presentation Language*
Presentation Language if Other
Event Type*
Event Name*
Event Date*
MM slash DD slash YYYY
Event Time*

: Hour

Month

AM/PM
Brokerage Firm/Agency*
Facility Type*
Facility Type if Other
Representative/Agent NPN Number*
Representative/Agent Name*
Venue Name*
Venue Phone*
Venue Address*
Venue Street Address Venue City Venue State Venue Zip Code
Event Contact*
Event Contact Phone*