Health Services Survey

Business NH Magazine is compiling information for its Small Business Healthcare Guide, which includes a listing of health care providers operating in NH. The guide will appear in the September 2005 issue.
This is a free listing. Please complete a separate survey for each of the following types of plans if applicable: HMO, POS, PPO, and indemnity. Please complete surveys by July 15, 2005.
If you have any questions or concerns, please call Managing Editor, Matt Mowry at 603-626-6354 ext. 214.

Type of plan (HMO, POS, PPO, Indemnity)
Name of company
Name of plan
Phone number
Fax number
Web Address
Total NH plan members
Total NH physicians
NCQA accreditation ranking
PCP required?
Are there out-of-network benefits offered (If Yes, please specify)
Office Copay Amount (give range)
Emergency Room Copay Amount (give range)
Prescription Copay Amount (give range)
Hospital Copay Amount (give range)
Maximum out-of-pocket Expense for Individual, Family
Types of alternative medicine covered
Types of preventative programs covered
Other programs covered
Name/title of person completing survey
Phone of person completing survey