SurveyMonkey Powered Online Survey

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* 1. Name:

First:

Last:

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* 2. Please check the title below that best represents your job responsibilities:

Practice Manager

Billing/Business Office Manager

HealthCheck Coordinator

Other (please specify)

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* 3. E-mail Address:

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* 4. Practice Name:

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* 5. Practice Address:

Street:

City:

ZIP:

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* 6. Practice Phone Number (include area code):

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* 7. How do you prefer to receive information from Security Health Plan? (check all that apply)

Phone

E-mail

Mailings

Online Portal

Other (please specify)