General 2019 Digital Health Products Application

Introduction - Company and Product Information

The Center for Health Care Strategies (CHCS) has created a curated database of digital health products that are designed to serve medically and socially complex, low-income populations. Our goal is to help catalog products that have specific experience with this population, and serve as a resource to stakeholders who are interested in exploring the space further. The information in this survey will be used to determine if your product will be featured in the database. Please fill out one application per product submission. The application will take 20-30 minutes to complete.

Note: You can save your survey and return to it later, but responses are saved by page. Once a page is submitted, you can no longer edit that page when you return to the survey.

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* 1. Company Name

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* 2. Company Website

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* 3. Company Address

Street

Apt/Suite

City

State

Zip Code

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* 4. Primary and Secondary Contact Information:

Contact #1 Name

Contact #1 Title

Contact #1 Email Address

Contact #2 Name

Contact #2 Title

Contact #2 Email Address

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* 5. Name of Product (if different from company name):

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* 6. Year company established:

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* 7. Year product established (if different from above):

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* 8. Brief product description (6 word limit). Click here for examples.

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* 9. Long product description (150 word limit).

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* 10. Describe your product's demonstrated and specific applicability to low-income populations with complex medical and social needs. This could include: previous initiatives or pilots; relevant use cases; partnerships with organizations specializing in complex populations; or other examples (300 word limit).

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* 11. How many employees work for your company?

1-9

10-49

50-99

100+

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* 12. Using the following definitions, select the category that best describes your funding stage:

Early

Intermediate

Advanced

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* 13. Select the category or categories that best describe your product's pricing structure:

Implementation/Installation Fee: Pricing is based on a one-time installation fee.

Licensing/Subscription/SaaS: Pricing is based on either a one-time, annual, or monthly licensing fee. Licensing and subscriptions may be per user or volume/enterprise-based.

Usage-based/On-demand: Pricing is based on how often individuals use the product.

Free.

Other (please specify)

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* 1. Company Name

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* 2. Company Website

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* 3. Company Address

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* 4. Primary and Secondary Contact Information:

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* 5. Name of Product (if different from company name):

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* 6. Year company established:

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* 7. Year product established (if different from above):

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* 8. Brief product description (6 word limit). Click here for examples.

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* 9. Long product description (150 word limit).

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* 11. How many employees work for your company?

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* 12. Using the following definitions, select the category that best describes your funding stage:

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* 13. Select the category or categories that best describe your product's pricing structure:

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* 14. Describe your product's privacy and security standards and protocols. (100 word limit)