Employer Questionnaire Form

Employer Questionairre
Does your company currently offer onsite health care services to employees?

No Yes
Are your health care services provided by a 3rd party vendor or managed in-house?

Third Party Direct through my company
What health care provider are you currently working with?
Why are you looking to make a switch?
What do you like about your current onsite health care services?
How many locations would you like to offer onsite health services for?
Estimate # of employees at this location:
Select this state where of this location:
Estimate # of employees at 2nd location:
Select this state where of 2nd location:
Estimate # of employees at 3rd location:
Select this state where of 3rd location:
Estimate # of employees at 4th location:
Select this state where of 4th location:
Estimate # of employees at 5th location:
Select this state where of 5th location:
Estimate # of employees at 6th location:
Select this state where of 6th location:
Estimate # of employees at 7th location:
Select this state where of 7th location:
Estimate # of employees at 8th location:
Select this state where of 8th location:
Estimate # of employees at 9th location:
Select this state where of 9th location:
Estimate # of employees at 10th location:
Select this state where of 10th location:
Would you like to include dependents as users of the onsite health services?

Yes No
Select the on-site health services you are interested in:

Primary Care Occupational Health Wellness Programs
Additional Services your company would like to find out more information about:

Telemedicine / Telehealth Chronic Condition Management Behavioral Health Health Screenings Physical Therapy Lab / Testing Pharmacy Radiology Dental Vision Biometric Screening Wellness Coaching Incentive Programs Nutrition Wellness Portal Fitness
What are your main initiatives for offering on-site health care? (select all that apply)

Better manage overall health spend Reduce member health risk Reduce absenteeism / increase presenteeism Increase employee productivity Manage chronic conditions Quality and/or consistency leadership image Attract and retain top talent Reduce/manage workplace injuries Other
If other, please explain:
What time frame are you expecting to make a decision about selecting an onsite health care vendor?
Are you working with a consultant or broker?

Yes No
Name of consultant/broker (optional):
Name

First Name Last Name
Job Title
Company
Phone Number

Area Code Phone Number
Email
example@example.com
Should be Empty:

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Employer Questionairre

Let's talk about what QuadMed can do for your business.