Easterseals Affiliates Insurance Contracts

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* 1. Which of the Following Insurance Companies do you Have Contracts With Currently?

Centene

Cigna

Kaiser Permanente

Anthem

Aetna

Blue Cross Blue Shield

Humana

United

Magellan

Amerigroup

Coventry

Molina

Tricare

Centpatico

Amerihealth

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* 2. Please list any other insurance companies you have contracts with that aren't listed above

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

Name of Insurer

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* 3. If you are offering services via telehealth at this time, please list the platforms you are using below.

Platform

Platform

Platform

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* 4. What tools are you using to provide telehealth services? Ex: ipads, cell phones, etc.

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* 5. What was the cost of your investment in Telehealth:

Under $10,000

$10,000 - $15,000

$15,000 – 20,000

More than $20,000

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* 6. Did you receive grants, discount pricing or in kind gifts that enabled you to fund telehealth?

Yes

No

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* 7. If yes, please describe:

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* 8. What is your affiliate?