| GENERAL INFO |
Company
and Plan Name |
|
| Phone
Number |
|
| E-mail |
|
| Website |
|
| PRICE
|
Cost
(premium)/Month |
|
| Cost
(premium)/Year |
|
| Co-Pay
Amount |
|
| Annual
Deductible |
|
| Co-Insurance
(%) |
|
| Annual
Limit/Cap |
|
| QUALITY
OF HEALTHCARE |
# of
Doctors in Network |
|
Qualified Providers (Physician and Hospital Report)
|
|
|NCQA and Other Ratings
|
|
| SUITABLE
HEALTH SERVICES |
Checklist of Medical Services You Require or May Require (Vision, Dental, Prescription
Drugs, Etc)
|
|
Preventative Programs
|
|
Psychotherapy |
|
Recovery Programs
|
|
Managing Current IllnessesGuaranteed Renewable?
|
|
Out of Network Services
|
|
| COMMENTS |
Comments from People Currently Enrolled in Program
|
|
Note: These are only suggestions. There may be
other important factors you should consider.
 Example of How to Fill Out
This Chart
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http://www.heartsandminds.org/health/blank.htm - online October 8, 2004 |
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