Eyecare Business
  Eyecare Business is free to qualified professionals. Summary Description
  To apply for a FREE subscription to Eyecare Business, please answer ALL of the questions on the form below.
  The publisher determines qualification and reserves the right to limit the number of free subscriptions.
  Geographic Eligibility: USA


 
1. Do you wish to receive a FREE subscription to Eyecare Business?
Yes     No


First Name:
Last Name:
Job Title:
(Ex: Director, Vice President, Project Manager, etc.)
Company:
(Please provide your Company Name in full: abbreviations could disqualify you)
Street Address:
Division/Mail Stop:
City:
State:
Country:
(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Zip/Postal Code:
Business Phone:
Business Fax:
Email Address:
(Note: Valid email address is required or you could be disqualified.)

  What is the approximate number of employees in your company? (select only one)
 
Yes, please auto-fill my contact information for other publication qualification forms.


2. May we contact you via email?
Yes     No


3. May we contact you via email on behalf of ophthalmic industry on topics pertinent to you?
Yes     No


4. May we contact you via fax?
Yes     No


5. Please check the ONE category that best describes your business/professional activity: (select only one)
DISPENSING OPTICIAN OPTOMETRIST cont.
Self-employed/owner Independent affiliated with retail corporation
Employee of retail corp(chain) Employee with retail corporation
Employee of independent optician Employee of O.D.
Employee of independent O.D. Employee of M.D.
Employee of independent M.D. Other optometrist (please specify)
Other dispensing optician (please specify)
OPHTHALMOLOGIST
OPTOMETRIST OPTICAL LAB/WHOLESALER
Solo practice EXECUTIVE/BUYER AT CHAIN HEADQUARTERS
Group practice OTHER (please specify)
Corporate franchise


6. What is the wholesale price range of the majority of the eyeglasses sold at your business? (select one only)
Over $150 $51 - $100
$100 - $150 Under $50


7. At your practice, of the spectacle lenses you dispense, what percentage are A/R coated?
%


8. What are the lens processing capabilities on-site at your business? (select all that apply)
Finishing (edging) Surfacing
Casting None


9. Do you buy, specify, approve or influence the purchase of contact lenses?
Yes     No


10. Do you fit contact lenses?
Yes     No


11. In lieu of a signature, we require a personal identifier. To verify that you submitted this application please enter below in what state were you born:


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  Please check the one category that best describes your title:  
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  Which of the following products do you recommend, specify or purchase? (select all that apply)  
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OR:    Name of the school you last attended:
Which of the following BEST describes the primary business of your organization or division? (select only one)
A. HEALTHCARE PLAN, PAYOR & ADMINISTRATIVE ORGANIZATIONS:
HMO/PPO/PSO/Insurance Company
Medicare/Medicaid/Governmental Plan
Supplemental/Carve-Out Insurance Plan (Dental/Vision/Behavioral Health)
Pharmacy Benefits Management (PBM) including Medicare Part D PDP
Third Party Administration (TPA)
Utilization Review Firm
Contract Management Firm
Group Purchasing Organization (GPO)
Employee Benefits Management (EBM) Firm/Consultant
Other Healthcare Plan, Payor & Administrative Organization
Please specify for Other:
B. HEALTHCARE PROVIDER ORGANIZATIONS: (An entity that directly treats patients)
Integrated Health Organization (IHO) (multi-hospital/practice settings; same ownership)
Integrated Delivery System (IDS) (multiple practice settings; same ownership)
Integrated Health Network (IHN) (multi-hospital; separate ownership)
Multi & Large Group Practice (50+ physicians)
Multi & Large Group Practice (less than 50 physicians)
Independent Hospital (300+ beds)
Independent Hospital (less than 300 beds)
Independent Practice Association (IPA)
Medical Clinic (50+ physicians)
Medical Clinic (less than 50 physicians)
Long-term Care Facility or Multi-Facility
Home Healthcare Organization
Other Healthcare Provider Organization
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C. INDEPENDENT CONSULTANT
D. NON-HEALTHCARE EMPLOYERS OF: (Aerospace, Automotive, Banking/Financing, Construction, Consumer Goods, Energy, Federal & State Government, Food/Grocery, IT–Hardware & Software, Retail)
5,000+ Employees
1,000 - 4,999 Employees
200-999 Employees
E. OTHER
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Which of the following titles & specialties BEST describes your highest current management position in the business organization selected in the above question? (select only one)
NON-CLINICAL EXECUTIVE:
Chief Executive: CEO/COO/President/Executive Director/Owner/Principal/VP/Director
Managed Care Executive: Chief/VP/Director
Administrative Executive: VP/Director
Financial Executive/Contracting Executive/Industry Relations Executive: CFO/VP/Director/Treasurer/Controller
Information Technology & Intelligence Services Executive: CIO/VP/Director (Software, Hardware, Web, Data Processing, Technology Assessment)
Medical Records Executive: VP/Director
Marketing Executive: CMO/VP/Director
Sales Executive: CSO/VP/Director
Patient Relations/Member Services Executive: VP/Director
Human Resources Executive: VP/Director
Employee Benefits Executive: VP/Director
Legal/Regulatory/Affairs Executive: Chief Counsel/VP/Director
Risk Management Executive: VP/Director
Other Non-Clinical Executive: VP/Director
Please specify for Other:
CLINICAL EXECUTIVE:
Medical Director
Chief of Medicine/Chief of Staff
VP/Director/Chief of Medical Affairs
Clinical Program Director/Services VP/Director (Specify: e.g., Oncology, Sports Medicine, Transplant, Disease, ER, Trauma, Wellness, Physical Therapy, Radiology, etc.)
Please specify:
Pharmacy/Formulary Director/Formulary Committee Chair
VP/Director/Chief of Pharmacy Services
Drug Information Officer/Clinical Pharmacist
VP/Director of Nursing/Chief of Nursing Affairs
Utilization Review/Quality Assurance VP/Director
Case Management VP/Director
Provider Relations VP/Director
Other Clinical Executive: VP/Director
Please specify for Other:
  Are you currently a P & T Committee member/presenter/contributor? Yes     No
  Total number of lives covered if at a Managed Care Plan/Payor Organization:
  Do you presently play a role in Pharmacy Benefits Design/Structure, Drug Choice and/or Implementation? Yes     No
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