Health Law Section's Directory Listing Application

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Health Law Section’s Directory Listing Application

You are invited to list your name or that of your law firm in the Health Law Section directory of D.C. area legal service providers who handle health-related legal matters for clients of modest means. If you or your law firm are currently listed in the directory, you may use this form to provide any necessary updates to your information. The directory is distributed by the D.C. Bar to community service groups who make referrals to attorneys for health-related matters, and it is also posted on the web site of the D.C. Bar Health Law Section. There is a $10 fee for a new listing. There is no charge for an update to a current listing.

1.	Proposed Provider—individual, law firm, or organization
	Name:
	Address:
	Telephone:
	Fax:
	E-Mail Address:

2.	In which jurisdictions is the practitioner licensed to practice law? Please include year in which provider was licensed?
	Jurisdiction and Year:
	Jurisdiction and Year:
	Jurisdiction and Year:
	Jurisdiction and Year:
	Jurisdiction and Year:

3.	What languages are spoken by the proposed provider and at what level of facility—fluent, conversational or limited?
	Language and Facility Level:
	Language and Facility Level:
	Language and Facility Level:
	Language and Facility Level:
	Language and Facility Level:

4.	What is the nature of the assistance offered by the provider? Check all that apply.
	Advisory assistance and legal counseling
	Representation of clients in a formal administrative hearing
	Representation of clients in litigation
	Alternate dispute resolution services
	Other (please explain)

5.	Please indicate below the types of issues for which the proposed provider will offer assistance. Check all that apply.
	Medicare eligibility, coverage, denials, and reimbursement matters
	Medicaid eligibility, coverage, denials, and reimbursement matters
	Other third party payor-related matters (e.g. coverage/denials, reimbursement, liability)
	Social Security eligibility, coverage/denials, and reimbursement matters
	Health care advance directives (e.g. living wills, health care durable powers of attorney)
	Americans with Disabilities Act matters
	Family and Medical Leave Act matters
	Civil commitment and rights of mentally ill
	Guardianships and conservatorships
	Patient rights (e.g. medical records issues, in-patient rights, right to refuse treatment)
	Bioethics issues, including withdrawal of medical treatment for incompetent persons
	Healthcare fraud and abuse
	Other (please explain)

6.	If you are currently listed in directory, has your listing resulted in any contacts from individuals seeking representation?
	yes
	no
	If yes, how many contacts?

7.	Please add any additional comments or information here if desired.

Please mail the completed survey form to the D.C. Bar Sections Office, 1250 H Street NW, Sixth Floor, Washington, DC 20005. If this is a new listing rather than an update of a current listing, please include a check for $10 payable to the D.C. Bar.

Some organizations or individuals who might be interested in appearing in the directory may not be on our mailing list. Please feel free to post this survey publicly or forward copies directly to interested providers. Questions may be directed to the Sections Office at 202-626-3463.