Coverage at Work Clinic Toolkit Form

	You’re taking a great first step in helping your patients secure insurance coverage for the medical treatments they need to build a family. Thank you for joining the access to care movement and sharing this important information about RESOLVE’s Coverage at Work program with your patients. Please fill out this quick form and you’ll receive an email with all of the collateral and information you need to encourage your patients to ask their employer for the family building benefits they deserve.
1.	Question - Not Required - Please send me the materials to share with my patients: Yes
*2.	Question - Required - What is your clinic name? (Maximum response 255 chars, approx. 5 rows of text)
3.	Please fill out the following information to receive the Coverage at Work materials: * Name: First Name Required  Last Name Required      * Email: Required * ZIP / Postal Code:   Phone Number:   Yes, I would like to continue or start receiving email communication from RESOLVE. (Note: RESOLVE does not share your information with third-parties and will only send emails related to Coverage at Work or appropriate for clinics to receive.)
*4.	Question - Required - How did you hear about the Coverage at Work Program? Please select response Website Friend/Colleague Medical Professional Social Media Post Other
5.	Question - Not Required - If you answered other, please explain below:

Spam Control Text:   Please leave this field empty