Managed Healthcare Executive Free Subscription

	*Managed Healthcare Executive* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Managed Healthcare Executive*, please answer ALL of the questions on the form below.
	The magazine publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Do you wish to receive a FREE subscription to Managed Healthcare Executive?*

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Yes, please auto-fill my contact information for other publication qualification forms.

2.	To permit future verification of your request, please answer ONE of the following questions:

What month were you born?

OR

Name of the school you last attended:

3.	Which of the following BEST describes the primary business of your organization or division? (select only one)

A. HEALTHCARE PLAN, PAYOR & ADMINISTRATIVE ORGANIZATIONS:

HMO/PPO/PSO/Insurance Company

Medicare/Medicaid/Governmental Plan

Supplemental/Carve-Out Insurance Plan (Dental/Vision/Behavioral Health)

Pharmacy Benefits Management (PBM) including Medicare Part D PDP

Third Party Administration (TPA)

Utilization Review Firm

Contract Management Firm

Group Purchasing Organization (GPO)

Employee Benefits Management (EBM) Firm/Consultant

Other Healthcare Plan, Payor & Administrative Organization (please specify)

B. HEALTHCARE PROVIDER ORGANIZATIONS: (An entity that directly treats patients)

Integrated Health Organization (IHO) (multi-hospital/practice settings; same ownership)

Integrated Delivery System (IDS) (multiple practice settings; same ownership)

Integrated Health Network (IHN) (multi-hospital; separate ownership)

Multi & Large Group Practice (50+ physicians)

Multi & Large Group Practice (less than 50 physicians)

Independent Hospital (300+ beds)

Independent Hospital (less than 300 beds)

Independent Practice Association (IPA)

Medical Clinic (50+ physicians)

Medical Clinic (less than 50 physicians)

Long-term Care Facility or Multi-Facility

Home Healthcare Organization

Other Healthcare Provider Organization (please specify)

C. INDEPENDENT CONSULTANT

D. NON-HEALTHCARE EMPLOYERS OF: (Aerospace, Automotive, Banking/Financing, Construction, Consumer Goods, Energy, Federal & State Government, Food/Grocery, IT–Hardware & Software, Retail)

5,000+ Employees

1,000 - 4,999 Employees

200-999 Employees

E. OTHER (please specify)

4.	Which of the following titles & specialties BEST describes your highest current management position in the business organization selected in question 3? (select only one)

NON-CLINICAL EXECUTIVE:

Chief Executive: CEO/COO/President/Executive Director/Owner/Principal/VP/Director

Managed Care Executive: Chief/VP/Director

Administrative Executive: VP/Director

Financial Executive/Contracting Executive/Industry Relations Executive: CFO/VP/Director/Treasurer/Controller

Information Technology & Intelligence Services Executive: CIO/VP/Director (Software, Hardware, Web, Data Processing, Technology Assessment)

Medical Records Executive: VP/Director

Marketing Executive: CMO/VP/Director

Sales Executive: CSO/VP/Director

Patient Relations/Member Services Executive: VP/Director

Human Resources Executive: VP/Director

Employee Benefits Executive: VP/Director

Legal/Regulatory/Affairs Executive: Chief Counsel/VP/Director

Risk Management Executive: VP/Director

Other Non-Clinical Executive: VP/Director (please specify)

CLINICAL EXECUTIVE:

Medical Director

Chief of Medicine/Chief of Staff

VP/Director/Chief of Medical Affairs

Clinical Program Director/Services VP/Director (Specify: e.g., Oncology, Sports Medicine, Transplant, Disease, ER, Trauma, Wellness, Physical Therapy, Radiology, etc.)

Pharmacy/Formulary Director/Formulary Committee Chair

VP/Director/Chief of Pharmacy Services

Drug Information Officer/Clinical Pharmacist

VP/Director of Nursing/Chief of Nursing Affairs

Utilization Review/Quality Assurance VP/Director

Case Management VP/Director

Provider Relations VP/Director

Other Clinical Executive: VP/Director (please specify)

5.	Are you currently a P & T Committee member/presenter/contributor?

Yes No

6.	Total number of lives covered if at a Managed Care Plan/Payor Organization: (select only one)

More than 5 Million 100,000-499,999

2.5-4.9 Million 75,000-99,999

1.0-2.4 Million 50,000-74,999

500,000-999,999 Less than 49,999

7.	Do you presently play a role in Pharmacy Benefits Design/Structure, Drug Choice and/or Implementation?

Yes No

8.	Tell us what you really think. Join our Managed Healthcare Executive Research Panel today.

Sign me up for 6-8 quick surveys per year at my email address.

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