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Employer Intake Form

If you have any problems filling out this form, please reach out to Teri Jones @ teri.jones@novohealth.com or call 833-361-6686.
 
* - required fields
COMPANY INFORMATION
Company *  
Street *  
City * / State * / Zip *  
First Name  
Last Name  
Phone  
How did you hear about
NOVO Health?		  
Number of Employees *  
Any NOVO Health
programs offered today? *		 Yes No  
If yes, please describe  
Do you currently participate
in any bundle programs? *		 Yes No  
If yes, please describe  
Broker Agency *  
Individual Broker *  
TPA *
Please choose from the list or if not listed or if you have additional TPAs type in the textbox provided below
 
Stop Loss *
Please choose from the list or if not listed or if you have additional Stop Loss Carriers type in the textbox provided below
 
Pharmacy Benefits Management Provider *  
Employee Assistance Program Provider *  
Provide on-site/near-site services *  
If yes, please describe  
SECTION 1: EMPLOYER CONTACTS
Primary Contact
Name *  
e-Mail *  
Title *  
Phone *  
Contact Authorized to Sign Contracts
Name *  
e-Mail *  
Title *  
Phone *  
Confidentality Agreement
Representative *
Authorized (employer)
Unauthorized (third party or broker - intake forms and program agreements cannot be processed until the confidentiality agreement has been additionally signed by the employer.)
 
Signature *  
Date Signed *  
PHI Authorization Contacts
First
Name *  
e-Mail *  
Title *  
Phone *  
Second
Name  
e-Mail  
Title  
Phone  
Section 2. Health and Dental Plans
Based on the number of plans, the next page will capture plan details
Number of Health Plans * 0 1 2 3  
Number of Dental Plans * 0 1 2  
Authorize HPS to share data Yes No  
Section 3. Workers' Compensation
TPA
providing claims services
  
Carrier
if fully insured for WC
  
Challenges
Employee turnover in connection with work-related injuries/illnesses
Establishment of reserves
Experience Modification Rate (MOD Rate, EMR, E-Mod)
Frequency/duration of off-duty recommendations
Loss Cost Multiplier
Lost time of employees
Musculoskeletal injuries
Other (Please describe)
Other:
 
Employer Implemented
Early intervention program to prevent escalation to OSHA recordable events
Ergonomic assessment of the worksite
On-site physical/occupational therapy
Other (Please describe)
Post-offer/pre-employment testing
Preferred provider or center of excellence program for triage and/or treatm
Preventative exercise/stretching program
Return-to-work program
Work hardening/conditioning program
Other:
 
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