Partner Intake Form "*" indicates required fields Step 1 of 7 14% Physician and Advanced Practice Provider Searches We pride ourselves on making good matches between providers and organizations. This is important to us because, like you, we know that it builds healthy teams and happy team members, increasing employee engagement and retention. Learning as much as we can about our valued partners is part of our proven process. We’ve found that the best way to learn about things that are foundational to your business and critical to candidates is through a combination of written responses and collaborative onboarding calls. This Intake Form is designed to gather mostly tactical, “fact-based” information about your organization and your search so that we can focus more on strategic direction on our collaborative calls. Some questions may be hard to answer; that’s okay! We can work through complex responses together. Section 1: Contact Information We can’t wait to get to know you. Tell us about the VIPs we’ll get to work with and how to get in contact with you. Organization InformationName of Practice / Facility*Organization Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Point of ContactPrimary Point of Contact Name* First Last Primary Point of Contact Job Title*Primary Point of Contact Email* Primary Point of Contact Phone Number*Additional Points of ContactHow Many Additional Points of Contact do you have?* None 1 2 3 4 Additional Point of Contact 1Additional Point of Contact Name 1* First Last Additional Point of Contact Job Title 1*Additional Point of Contact Email 1* Additional Point of Contact Phone Number 1*Additional Point of Contact 2Additional Point of Contact Name 2* First Last Additional Point of Contact Job Title 2*Additional Point of Contact Email 2* Additional Point of Contact Phone Number 2*Additional Point of Contact 3Additional Point of Contact Name 3* First Last Additional Point of Contact Job Title 3*Additional Point of Contact Email 3* Additional Point of Contact Phone Number 3*Additional Point of Contact 4Additional Point of Contact Name 4* First Last Additional Point of Contact Job Title 4*Additional Point of Contact Email 4* Additional Point of Contact Phone Number 4* Section 2: Overview of Your Organization and Your Need Tell us a little about your organization and your current search to help us understand you, your overall goals and how we can help. 1. Describe your organization type and structure (for example, we’re a chain of 30 family practices organized into two regions).*2. Please share a brief history of your practice.*3. Tell us a little about your culture. You can share things like your mission, an overview of how the staff interacts, or anything that would give us an idea of what it means to be part of your team.*4. Please describe your current recruitment needs.*5. Tell us a little about your reasons for your current search.*6. How long have you been recruiting for this opportunity?*7. What recruiting resources have you used so far?*8. Have you had any on-site interviews? Offers extended? Why do you feel you have been unsuccessful?*9. Do you have any retention or turnover issues? Please explain.*10. Are there any recent additions to your current team / location? Can you tell us about the experience of bringing them into your organization?*11. Are you currently speaking with any candidates? If so, please provide their names so we can exclude them from the search.*12. How many total providers do you have (physicians and APPs)?*13. How many patients do your providers typically carry on their panel? What is the goal / target if for some reason those numbers are not in sync?*14. What is your practice patient mix by payer type (% Medicare, %Medicaid, %Commercial, etc.)?*15. What is the average wait time to schedule new / existing patients?*16. What is your EMR (Electronic Medical Records) system?*17. We would love to know what truly differentiates your organization- what do you do that others don’t, and how does it set you apart?* Section 3: The Provider Experience at Your Practice / Facility Help us tell your future team members more about what it will be like to join your organization.18. What are the overall duties / expectations of your physicians? Please detail a “day in the life.”*19. Please describe the productivity expectations for each provider. For example, the number of daily slots covered or number of patients per day per provider.*20. How much time is allotted for new patient visits and follow ups?*21. What is the no-show rate?*22. How many hours a week for each provider are patient-facing, and how many are administrative?*23. What are the call coverage expectations for each provider per week?*24. Is there a stipend for being on call? If so, what is it?*25. Tell us about the support staff for each provider. For example, does each have a designated MA?*26. Is there anything else that will set us apart and create a wonderful experience for patients and providers? For example, do you have an on-site lab, x-ray, MRI, pharmacy, or other opportunity that makes your patient / provider experience unique?* Section 4: Candidate Eligibility Each organization has unique requirements for hiring providers. Let’s learn more about yours. 27. Please list your candidate qualifications.*28. Will you accept Board Eligible candidates?*29. Will you accept new graduates?*30. Can you accept Visa candidates (H1B, J1, etc.)?*31. List any specific training or fellowships you’re looking for in candidates.*32. Tell us about any unique qualities you would like to see in your candidates.* Section 5: Provider Compensation and Benefits at Your Practice / Facility Total compensation packages are a key component of a candidate’s interest and decision.33. What is the base salary range for an experienced provider?*34. If different, what is the base salary range for a new graduate?*35. What is your annual provider incentive / bonus structure? How are the providers incentivized above their base salary (Quality Bonus, Productivity Bonus, Retention Bonus, etc.)? Please provide details on each.*36. Tell us about any other bonuses or incentives (sign-on bonus, recruitment incentive, forgivable loan, etc.).*37. Have you offered a separate relocation package for providers moving to the area? Please provide details.*38. What are the other providers in similar roles making, on average? Please explain the total earning potential (not including benefits) of a candidate.*39. Do you have a partnership track? Please describe.*40. Please detail your health insurance package, including dental and vision, as well as any employee cost sharing. If you have a document you typically share with candidates that provides them with an overview, please share that with us.Max. file size: 128 MB. 41. Describe your retirement vehicles offered to providers. (401K, 403(b), 457(b), Profit Sharing, etc.).*42. Tell us about your PTO policy (accrual, additional time for length of service, etc.).*43. Describe your CME days and any allowance.*44. Please detail any student loan repayment benefits available through your organization or those you qualify for through state and/or federal agencies.*45. Is your malpractice insurance policy claims-made- or occurrence-based? If claims-made, who is responsible for tail if/when the provider leaves the organization? Please provide details if it is shared or variable.*46. Do you offer any other benefits that a candidate would have access to? (life insurance, discount cards, etc.)* Section 6: Your Hiring Process Our goal is to deliver fully-screened, highly qualified candidates who are well-informed about your organization and the opportunity. We handle the heavy lifting so you can focus solely on determining whether the provider is the right fit. We also recognize that an efficient hiring process is the other half of the equation – when we have that in place, it not only accelerates results but also differentiates us from competitors who are also vying for the provider’s attention. In the interest of helping us prepare candidates for what’s to come, let’s discuss what happens once a provider had been officially submitted to you for consideration.47. Who initiates the first screen with the candidate? Assuming mutual interest exists, what is the next step?*48. Tell us about the onsite interview. Who is involved? What does the experience look like?*49. Who will be the ultimate decision maker for a hiring decision?*50. How are offers extended? Do you utilize an offer letter or employment agreement, or both?* Section 7: Additional Information51. Please provide any additional information that you think would help us in our search.
