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Buckeye Health Plan Mobile Van Request Form

The Buckeye HealthConnect van is bringing needed health services to our local communities. Are you hosting a health fair, back to school drive, food distribution or large community event or gathering in Central Ohio? Are you a health care provider that we can partner with to help address community needs? Interested in collaborating to provide health care services in Central Ohio? To request the Mobile Van be in attendance for your event, please fill out the information below.

Are you a Buckeye Health Plan Employee?
What type of event are you requesting?
Community Event- Giveaways and Resources only Provider Community Event - Clinical/ Health Screenings/Vaccines
Event Request Type
Event Description
  • {name}
Event Location
Location must be secured before requesting Van.
Tell us more about the location *Please select all that apply
Location will need to be secured before completing form.
If the event is on different days please complete a new form for each event.
26. What would you like Buckeye Health Plan to provide? Please select all that apply
Have you obtained permits required for parking?
Is there an ability to park near a power box?
Does your power service support 30 amp?
Is there access and parking availability for our 164'' by 98'' van?
Is there flexibility to allow at least half an hour of set up time for the mobile unit?
Please provide additional event details and information here
  • {name}
Please upload additional files and/or a parking map here
Submission of diagram of event space, where van will be parked and agreement from the organization to have the van on site will need to be completed prior to this request.
Attach file
Drop files here
How did you hear about this opportunity?
Additional Comments
  • {name}

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