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:

* 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):

* 3. Please indicate your own size, service area type, services/initiatives, and 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

* 6. The top 3 challenges you will need to address this year are:

* 7. Do you have any significant experience with:

  Yes No
Managed Care - public (ie. Medicaid) 
Managed Care - private (3rd party insurance)
ACOs
At-risk contracting 

* 8. Are you currently looking to merge, acquire, or be acquired?

* 9. Your top 3 non-work-related hobbies or interests are:

* 10. Potential peers you think might be a good fit for a peer group with you are:

Thank you for your interest!

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