Coalition Sign-Up Form
YES! You may list my organization as a supporter of Californians Allied for Patient Protection
(CAPP), a coalition of hospitals, community clinics, health centers, physicians, healthcare
providers, medical groups, local government, labor and business dedicated to protecting
California’s Medical Injury Compensation Reform Act (MICRA). MICRA ensures injured patients receive
fair compensation while also preserving patients' access to healthcare by keeping doctors, nurses and
healthcare providers in practice and hospitals and clinics open.
Please complete the following information:
Organization Name
(How should the organization be listed in CAPP’s materials?)
Name
Title/Occupation
Organization Address
City
State
Zip
________________________________________________________________________________________
Phone
Fax
E-Mail Address
Signature
Date
Return this form to:
Marissa Allen, Government Affairs Coordinator
Californians Allied for Patient Protection
1215 K Street, Suite 2015
Sacramento, CA 95814
Fax: 916-448-0234
[email protected]