New Mexico Coalition for Healthcare Value Membership Application

Thank you for your interest in the New Mexico Coalition for Healthcare Value.

Please complete this form regarding your organization’s New Mexico operations. Having a better picture of the characteristics of coalition members gives the Board of Directors and Committees a clearer idea of what would be of most value to members.

Name of Organization(*)
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Address(*)
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City(*)
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State(*)
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Zip code(*)
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Primary Contact(*)
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Title(*)
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Phone(*)
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Cell
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Fax
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E-mail(*)
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Type of Organization(*)

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Organization Information(*)
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(please state briefly the business function of your organization)

If Health Care Provider - Number of providers in New Mexico
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If Hospital - Number of beds
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Number of employees
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Number of employees in New Mexico
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Do you self-insure?
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Approximately what percentage of your covered lives is through self-insurance
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Do you purchase fully insured products from health plans?
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Please list the health plans you currently contract with
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Approximate number of covered lives:

Employees
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Dependants
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Retirees
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Total Covered Lives
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You may also download the form and mail or email it to us.

The New Mexico Coalition for Healthcare Value is a 501 (c) (3) organization
Tax identification number is 47-3664000