Exit this survey Peer Group Interest Questionnaire Please complete this form to provide information that we can use to match you with a group:* = Answered required * 1. Please provide your Contact information: Name Company Job Title 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 * 2. 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 * 3. 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: * 4. 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.) * 5. Please estimate what percentage of your annual revenue is from Medicaid State funding Private pay/insurance * 6. The top 3 challenges you will need to address this year are: Challenge 1: Challenge 2 Challenge 3 * 7. Do you have any significant experience with: Yes No Managed Care - public (ie. Medicaid) Managed Care - public (ie. Medicaid) Yes Managed Care - public (ie. Medicaid) No Managed Care - private (3rd party insurance) Managed Care - private (3rd party insurance) Yes Managed Care - private (3rd party insurance) No ACOs ACOs Yes ACOs No At-risk contracting At-risk contracting Yes At-risk contracting No * 8. Are you currently looking to merge, acquire, or be acquired? Yes No Additional comments on M&A: * 9. Your top 3 non-work-related hobbies or interests are: 1 2 3 * 10. Potential peers you think might be a good fit for a peer group with you are: Thank you for your interest! Submit
