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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
NOVO Health may make commercially sensitive information available to Employer in response to the information you have provided on this form. Examples of such information would include proposed contracts for your review, pricing, and other proprietary information. Before disclosing these types of sensitive information, we are requesting your agreement to keep such information confidential. Please review the statements below and check the box that applies to you:
Representative *
Authorized Employee

On behalf of the Employer listed at the top of this form, I agree that if NOVO Health makes commercially sensitive information available to the Employer about NOVO Health programs (such as pricing, contracts and other proprietary information), the Employer will keep that information confidential. The Employer will use reasonable means to protect such information, including the means it uses to protect the confidential information of its own business. If Employer chooses not to enter into an agreement with NOVO Health, or ends its participation in NOVO Health program, Employer will destroy or return NOVO Health's confidential information.

I'm a third party representative (broker, consultant, etc.)

I agree that in assisting this employer I will keep confidential and cause others in my company to keep confidential any of the commercially sensitive information shared with my customer or with me by NOVO Health. I understand that this intake form cannot be processed until an authorized representative of my customer (the employer with the health plan) signs a confidentiality agreement.

This can be done electronically, please send your customer the following link: Employer Confidentiality Agreement Form
 
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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