Peer Group Interest Questionnaire Please complete this form to provide information that we can use to match you with a group:* = Answered required Question Title * 1. Please provide your Contact information: (Required.) Name * Company * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Email Address * Phone Number Question Title * 2. Please provide the name and email of your EA for future peer meeting scheduling purposes. (Required.) Question Title * 3. Please rate the following 4 items in the order of importance to you as they related to identifying potential peers (1=Most to 4=Least): 1 2 3 4 Similar-sized organizations 1 2 3 4 Similar service area type (Urban, Rural, Suburban) 1 2 3 4 Similar priority services or initiatives 1 2 3 4 Similar vision Question Title * 4. Please indicate your own size, service area type, services/initiatives, and vision: Budget size (in Millions): Number of All FTEs: Number of Clinical FTEs: Service area type (Urban, Rural, Suburban, Mixed): Services / Initiatives: Vision: Question Title * 5. Please describe how your state's Medicaid program is administered (for example: fee for service, capitated, what MCOs are involved, is behavioral health carved in/carved out, etc.) Question Title * 6. Please estimate what percentage of your annual revenue is from Medicaid State funding Private pay/insurance Question Title * 7. The top 3 challenges you will need to address this year are: Challenge 1: Challenge 2 Challenge 3 Question Title * 8. Are you currently looking to merge, acquire, or be acquired? Yes No Additional comments on M&A: Question Title * 9. Your top 3 non-work-related hobbies or interests are: 1 2 3 Question Title * 10. Potential peers you think might be a good fit for a peer group with you are: Thank you for your interest! Submit
