City of OKC - Clinic RFP Vendor Questionnaire DRAFT 3.12.25.xlsx
XLSX spreadsheet 495 KB Posted
- Attached to
- Employee Medical Center Program
- Solicitation number
- RFP-OCMFA-043
- Issued by
- Oklahoma
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Other files
| File | Type | Posted |
|---|---|---|
| Sample Professional Services Agreement.pdf | ||
| Sample RFP Acord Form.pdf | ||
| Letter of Authorization.pdf | ||
| General Instructions.pdf | ||
| RFP Notice to Proposers Clinic.pdf | ||
| Utilization JL.pdf | ||
| RFP Special Provisions Clinic.pdf |
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Front Cover
Request for Proposal - Employee Medical Center Program
City of Oklahoma City
| Prepared by: |
| Lockton Companies, LLC |
| 2100 Ross Avenue, Suite 1200 |
| Dallas, TX 75201 |
| (214) 969-6100 phone |
| www.lockton.com |
RFP Overview City of Oklahoma City RFP for Near-Site Clinic
| OVERVIEW |
| City of Oklahoma City is performing an RFP for their current onsite clinic and pharmacy. The current clinic is run by Premise Health. The City of Oklahoma City has a self-funded medical and pharmacy plan which is administered by BCBSOK. The request is to quote services for on-site clinical and pharmacy services. The current clinic offers a limited amount of prescriptions onsite and mail order through a limited formulary. |
Effective Date: 1/1/2026
Commission Level: Net of Commission
| General Instructions |
| The RFP has the questions broken out between 3 tabs. Each question should be answered. If question is not applicable to your submission, please indicate "N/A". |
The RFP has pricing broken out between 3 tabs. Each tab should be addressed and answered - do not simply reference your proposal documents. Each cell of the grid needs to be filled out. Please include all original pricing proposal documents to your RFP response.
Utilization Data has been provided for any analysis you may be including with your offer.
Company Information
| Company Information |
| Company Name |
| Contact Name & Title |
| Address |
| City, State, Zip Code |
| Phone Number |
| Fax Number |
| Email Address |
| Federal Tax ID |
References
| Of these references, please include two municipalities. References should be based on the office that will be providing services to the CITY. | |
| Current Client - Reference 1 | |
| Organization name: | Contact and title: |
| Address: | Phone number: |
| Effective date of contract: | # of enrolled employees: |
| Description of services provided: | |
| E-mail address: | |
| Current Client - Reference 2 | |
| Organization name: | Contact and title: |
| Address: | Phone number: |
| Effective date of contract: | # of enrolled employees: |
| Description of services provided: | |
| E-mail address: | |
| Current Client - Reference 3 | |
| Organization name: | Contact and title: |
| Address: | Phone number: |
| Effective date of contract: | # of enrolled employees: |
| Description of services provided: | |
| E-mail address: | |
| Former Client - Reference 1 | |
| Organization name: | Contact and title: |
| Address: | Phone number: |
| Effective date of contract: | # of enrolled employees: |
| Description of services provided: | |
| E-mail address: |
General Questions General Questionnaire
| Company Information | Near-site Clinic Response |
| Please identify your company's ownership structure (sole proprietorship, general partnership, limited partnership, corporation, other) | |
| If the company is a sole proprietorship please list the owner's full legal name, the name under which business is conducted (i.e. d/b/a), the address for the company, including the state and county in which your business is located. | |
| If the company is a general partnership please list the exact name of the partnership, whether it is a partnership formed under the laws of the State of Oklahoma or another state, the business address for the partnership, including the state and county, and list of names of all of the partners for the partnership. | |
| If the company is a limited partnership please list the exact name of the limited partnership, whether it is a limited partnership formed under the laws of the State of Oklahoma or another state, the business address for the limited partnership, including the state and county, and list of names of all of the general partners for the partnership. | |
| - In the case of a limited partnership (foreign of domestic), is it registered with Secretary of State |
of the State of Oklahoma and authorized to do business in this State?
- In the case of a limited partnership (foreign of domestic), is its general partner(s) registered with Secretary of State of the State of Oklahoma and authorized to do business in this State?
| If the company is a corporation please list the exact name of the corporation, whether it is a corporation formed under the laws of the State of Oklahoma or another state, the business address for the corporation, including the state and county, and list of names of all of the officers for the corporation. |
| - In the case of a corporation (foreign of domestic), is it registered with Secretary of State of the |
State of Oklahoma and authorized to do business in this State?
| If the company is a limited liability company ("LLC") please list the exact name of the LLC, whether it is a LLC formed under the laws of the State of Oklahoma or another state, the business address for the LLC, including the state and county, and list of names of all of the members/managers for the LLC. |
| - In the case of a LLC (foreign of domestic), is it registered with Secretary of State of the State of |
Oklahoma and authorized to do business in this State?
| If the company is another entity not listed above, please list the exact name and type of company, the state under which it is formed, the business address for the company, include the state and county, and list the names of all the persons authorized to act on the company's behalf. |
| - In the case of another entity (foreign of domestic), is it registered with Secretary of State of |
the State of Oklahoma and authorized to do business in this State?
| If selected as a finalist, confirm that you would be able produce a financial report (for example: a profit/loss statement, balance statements and/or equivalent earnings statements) as part of your presentation and best and final offer? |
| Confirm if your organization has filed for bankruptcy in the past 10 years. |
| Confirm if your organization has recapitalized in the past 10 years. |
| Confirm if your organization is up for sell. |
| Describe how your organization will support a transition in the event of contract termination? |
| Please state what records would belong to us upon contract termination. How would the records be transferred? |
| Data Sharing/Integration |
| Does your firm have any current data sharing/integration agreements with the current medical plan administrator BCBSOK? |
| Have you had any experience sharing and integrating data with other carriers/administrators? |
| Describe the necessary steps to integrate data with 3rd party vendors (e.g. agreements, testing) |
| What data elements does your firm normally provide to a customer's 3rd party vendors? |
| Are your data file feeds specifications customizable? Please include as a separate attachment of your standard data file layout. |
| Please describe your data warehouse and predictive modeling capabilities. |
| HIPAA Compliance & Security |
| Please describe your training process and procedures the handling of PHI. |
| Describe your system for the assurance of personal health data security. |
| Have your network security systems ever been breached? Describe. |
| How often are the business continuity and disaster recovery plans tested and reviewed? |
| Please provide an executive summary (suitable for sharing) from the most recent certification, compliance, or penetration security testing performed on the SaaS provider’s hosting infrastructure. The summary should include date of testing, name of 3rd testing party agency, high level narrative of testing was performed, and results summary. |
| Liability Insurance |
| Confirm you will maintain primary commercial general liability insurance with limits of not less than $5 |
million per occurrence combined single limit. (A combination of primary and excess liability coverage can be used to meet this requirement) Confirm you will maintain Medical Malpractice and Managed Care Errors and Omissions Insurance at limits of not less than $5 million per claim.
| Confirm you will maintain Commercial Automobile Liability insurance with limits of not less than $5 million per occurrence combined single limit. Said policy should provide coverage for owned, hired and non-owned autos. |
| Confirm you will name client as an additional insured on both your primary and excess insurance policies. |
| Confirm your policies will be primary and non-contributory and also provide a waiver of subrogation on behalf of client. |
| Confirm you will maintain Worker's Compensation Insurance with at least minimum statutory limits of coverage within the state(s) of employment. Also, must maintain employer's liability insurance in an amount equal to or great than $1,000,000 each accident, Disease-Policy Limit and Disease-Each Employee. |
| Confirm at termination of the contractual relationship, you will purchase “tail” coverage for the |
professional liability insurance protection associated with the period services were provided, to cover any future period claims.
| Confirm you will provide prior written notice of at least 30 days to client of the cancellation or proposed cancellation of the insurance policy. |
| Confirm you will indemnify and hold harmless Client and its officers, directors, affiliates, |
employees and agents, from and against any claims, liabilities, losses or expenses, including with out limitation reasonable attorneys’ fees, arising or resulting from the negligent performance of professional services or acts and omissions of the Provider.
Confirm if the Nurse Practitioner, Doctor or the Group that such medical personnel are affiliated with are “independent contractors”, separate from the Provider itself, then such Nurse Practitioner/Doctor/Group will also need to meet the requirements set forth above in items 1-6.
Please disclose any excess limits of insurance that you will carry above the amounts set out above.
Please disclose any suits or settlements that you have entered into during the last five (5) years. If any such information is subject to confidentiality or similar agreements, please provide as much information as possible (facts, subject of claims, etc.) without disclosing the confidential information.
Please provide a copy of your standard agreement for services and indicate any non-negotiable terms in the agreement.
| Client Requirements |
| Please outline what requirements you have for the client from an IT/Telecommunications perspective (i.e.. Voicemail, toll free lines, etc.) |
| Please outline any supplies required to be provided by the client (i.e.. Soap, paper towels, etc.) |
| Please outline any furniture and space requirements to be provided by the client. |
| Note - the City owns the space that the clinic currently resides in. The new vendor would not be responsible for finding and securing a space. |
| Account Management |
| Who will be the day to day contact from your organization for the implementation process? |
| What is their background and experience? |
| Where is this person located? |
| Who will be the day to day contact from your organization for ongoing operation of the clinic? |
| What is their background and experience? |
| How many clients does this day to day contact currently work on? |
| Will they host monthly meetings to review the clinic performance, utilization and trends? |
| Will they be available at least once a year to come onsite for open enrollment meetings? |
| Recruiting, Credentialing, Background checks |
| How long on average does it take to recruit the clinic employees? |
| How does your company assess the credentialing of licensed employees for the clinic? |
| Is there a background check done on potential employees? |
| What specifically is reviewed during this process? |
| What is the employer's role in the recruiting process? |
| Who has the final authority on who is hired? |
| When does recruiting for clinic employees start? |
| Does your organization apply for in network status with the major carriers in the market? (Cigna, Blue Cross Blue Shield, UnitedHealthcare and Aetna) |
| Is the current clinic staff eligible to apply for the positions? If so, outline the process |
| Clinic Employee Orientation |
| How many hours of training are provided for each employee in the clinic? |
| Where does that training occur? |
| What ongoing training provided if any? |
| What is the frequency of the ongoing training? |
| Does the employer have the opportunity to provide any input into the training of clinic employees? |
| Employee Retention |
| Are clinic staff considered employees of your organization or are they considered contractors? |
| Are employees paid with a salary/hourly or are they paid based on the number of visits provided (fee for service)? |
| How are employees evaluated for performance? Please list categories of what is included. |
| How frequently are reviews completed? |
| How is coverage provided if a clinician is not able to attend the clinic during their scheduled shift? |
| If someone terminates, how do you ensure ongoing clinic operations while a new employee/clinician is hired? |
| If outside temporary staff are used in the above circumstances, how do you monitor quality and patient satisfaction of these providers? |
| How is the employer charged for temporary staff if a provider terminates or is absent for an extended time? |
| Do you have a non-compete for your providers? |
| Are you willing to guarantee no job is vacant with temporary fill for greater than 60 days? |
| What is the longest time period you have had a client job vacancy? |
| Business Continuity, Data Security, Risk, & Quality Management |
| Please describe your risk management plans and policies. Provide the last date that a Business Risk Assessment was completed, detail the high and medium risk factors and threats identified and describe your plans for remediating and/or mitigating each including timelines. |
| Describe any business continuity plans in place including disaster recovery planning. Indicate how often tests of the plan are conducted and characterize the success of the most recent test. |
| How will your organization handle information that includes personally identifiable information? |
| Has your company experienced a security breech? If so, when? |
| How have you or will you handle security breaches? Please describe in detail. |
| Please describe your security policies and procedures in relation to the clinic and technology. |
| Do you require your subcontractors to have security measures in place? If yes, please describe. |
| Has your organization earned any widely-recognized certifications for cybersecurity? |
| Describe security measures that you will employ onsite, including physical access controls, badging, and physical access monitoring. |
| Reporting Capabilities |
| Please provide examples of standard reports you provide to measure efficiency and effectiveness of the clinic. |
| Are you able to report on a monthly basis? |
| Program Measurement & Evaluation |
| Describe how you measure the efficacy of your programs. Include a description of the metrics used to gauge your compliance with your clients’ expectations. Please describe how this information is reported. |
| Leveraging the medical claims included with this Request for Proposal, please provide insight into the following performance metrics: |
| - Savings relative to more appropriate utilization management |
| - Savings relative to direct costs |
| - Savings relative to indirect costs |
| - Annual savings relative to total claims paid and medical trend |
| - Return on Investment |
| Please provide a description of the methodology and formula used to report outcomes in the following areas: |
| - Financial (i.e., ROI, savings, etc.) |
| - Clinical (i.e. clinical outcomes, etc.) |
| - Utilization (educational, coaching services, etc.) |
| - Member satisfaction |
| - Productivity impact |
| Lockton InfoLock Information |
| Will you provide Lockton a claims extract in their required format? |
| Is every procedure that happens in the clinic recorded with a valid CPT code? |
| Does the clinic collect SSNs. Will they share with Lockton? |
| Would the claims extract contain financials? Member copay, plan paid, allowed amount. If it includes plan paid, what does that number represent/how is it calculated? |
| If drugs are being provided in the clinic, can you provide the drug information by NDC code? |
| Can you provide days supply and metric quantity for drugs? |
| What information can you provide around coaching (dates, reasons for coaching, etc.)? |
| Can you provide a biometric file with lab results (i.e. height, weight, blood pressure, cholesterol, glucose, etc.)? |
| Do you provide NPI in your claims extract? |
| Do you send data to the medical carrier for integration? |
| Does data to the medical carrier include all procedures includes those that would not be paid in a typical medical care setting? |
| Performance Guarantees |
| What percent of total fees will you put at risk for implementation? |
| What percent of total fees will you put at-risk for client satisfaction? |
| What percent of total fees will you put at-risk for outcomes? |
| What percent of fees will you put at-risk for participant satisfaction? |
| Describe additional administrative and operational guarantees (e.g.) service guarantees that you will offer and the percent of fees which you will place at-risk. |
| Please provide the service and outcomes risk model for our review (if applicable) |
| Technology |
| Please describe your IT requirement for Network access, modem installation and other requirements to provide service access to the clinic. Who handles installation and what is the expected cost? |
| Please describe your requirements for computers, scanners, monitors and other IT equipment necessary to run the clinic. Who handles installation and what is the expected cost? |
| How often do you expect an upgrade to system components (computers etc.) and cost of upgrade? |
| Is there a monthly IT cost charged to Client? |
| What data security measures to you have in place and how will you indemnify the Company for data breaches where confidential medical information is obtained by a third party? |
| Telemedicine |
| Do you have a Telemedicine option for employees & dependents that are able to go to the clinic? |
| Are there any service limitations to telemedicine? |
| Who is your Telemedicine vendor? (if applicable) |
| Are patients able to use Telemedicine to connect with the clinic for a diagnosis? |
| Are you able to provide coaching for members not within the clinic area? |
| What security precautions are in place for telemedicine? |
| What your “scope of Practice” guidelines in the management of clinical care? |
&P &"Garamond,Italic"2007 Lockton Companies, LLC
PCMH Questions
| Patient Centered Medical Home Questionnaire | |
| Technology: | Response for Near-site Clinic |
| Technology: Please confirm your clinic management technology and electronic medical records can assist in the below compliance requirements and that licensing is for all users: | |
| - Participant Demographics | |
| - Scheduling | |
| - Encounter data collection and flow | |
| - Interface Capability: Radiology, Laboratory Reference Lab (with Take Care standard reference lab) and E-Prescribing | |
| - Scanning & Upload Capability | |
| - Insurance ID Card | |
| - Participant History | |
| - Laboratory-On Site | |
| - Other onsite testing | |
| - Real time Patient Management | |
| - Referral Tracking | |
| - Clinical Resources / Evidence Based Information | |
| - Claims processing | |
| - Co-pay collections | |
| - A/R Management / Reporting | |
| Additional Services available within your tool, that are not listed above | |
| Overall Care: | |
| How are appointments scheduled? | |
| Is the appointment scheduling process available online? | |
| Describe the availability of drugs at the clinic. Will there be a full range of acute and maintenance medications or a narrower formulary of available drugs? How do you ensure sufficient inventory at all times? | |
| Describe how your firm could implement a mail order program for maintenance drugs (i.e., 90-day program). | |
| Describe how you envision the clinic will reduce prescription drug expenditures for the client’s health plans. | |
| Indicate the dollar volume of the initial inventory. Describe the process for inventory control, security, renewal and billing. | |
| Are you affiliated with any major chain pharmacies? | |
| Explain your notification process for triaging more complex patient situations that are beyond 'normal' primary care | |
| Describe the physician's oversight of the clinic's functions. | |
| Describe the primary care case management process. | |
| Will you provide emergency response outside the clinic's space if something happens still on business property/grounds? | |
| What procedures do you have in place if after hours care is necessary? | |
| Do your clinicians have appropriate state licensing and certifications necessary to practice in the clinic? Is your medical staff certified to perform CPR and have they met state mandated criteria for providing clinical care i.e. TB exams etc. | |
| What level of indemnification do you provide to our Company for malpractice and other charges against your Company and or your clinicians. | |
| Communication Plan & Member Services: | |
| Please provide a proposed communication plan for introducing the onsite healthcare and wellness program and reference the ongoing communication process. Outline your company’s responsibilities in these processes. Please include copies of your educational materials and timelines for distribution. | |
| How can employees communicate with the clinic's medical team? | |
| Will you utilize existing resources for the clinic? | |
| Do you utilize an electronic medical record and if so which one? | |
| Can you electronically transmit claims and check deductible status with client Health Plan Administrator, BCBSOK? | |
| Can your website be linked with the Client website? | |
| Can an employee access your company for Member Services after hours and for appointment scheduling? | |
| Are you willing to use Client's own branding in your communication and program materials? | |
| What is the implementation timeline from contract signature to clinic being open? How many weeks per clinic? | |
| Identification of High Risk Individuals: (if there is an additional cost for any of these services, please specify) | |
| Understanding that there are a variety of methodologies for implementing a high risk individual intervention process, please explain in detail the model that your organization would recommend. Explain the rationale behind your recommendation. Please keep in mind that this needs to be a confidential process following all HIPAA guidelines. | |
| How would your company identify high-risk members (i.e. health risk assessment, member services calls, medical claims data, pharmacy claims data, etc.)? | |
| Describe your procedures for communicating with patients who have a specific condition or disease. | |
| - What conditions and diseases would qualify a member for your outreach communications? | |
| Describe your procedures for communicating with patients who would benefit from wellness. | |
| - What indicators would qualify a members for your wellness outreach communications? | |
| Describe your process for encouraging at-risk members to make their follow-up visits. | |
| Do you stratify members by severity of risk for complication? | |
| What level of participation can we expect in years one, two and three of this program? | |
| Describe how your organization will set and reach participation and engagement goals? | |
| - How do you define participation? | |
| - How do you define engagement? | |
| Explain your participation experience when incentives are used compared to when they are not used. | |
| Describe your capabilities for providing on-site finger stick biometric testing. | |
| Please describe your plan to involve new employees in the HRA process. | |
| Please describe your capabilities to update an individual’s HRA record and/or risk profile while conducting follow-up calls. | |
| How does your HRA monitor and report individual change from year to year? | |
| What are the specific risk factors you measure for and what are the qualifying metrics? | |
| What Health Risk Assessment (HRA) tool do you use if any? Do you have a partnership with a third party to conduct HRAs. If a third party is used for an HRA do you have data agreements and security measures in place. | |
| Do you provide blood testing to identify risks? Finger stick or blood draw? How do you have blood testing (draw) analyzed? Do you work with a partnership vendor for these services? | |
| What incentives do you provide/recommend in order to get employees to participate in health screenings? | |
| Intervention: | |
| For each of the following services, indicate whether the service is available today, is in development, or could be considered for development. If such service is available, please describe your capabilities: | |
| - Quality assurance and quality improvement programs. | |
| - Engaging the targeted individual. | |
| - Improving participation and reaching members who have not visited the clinic. | |
| - If a member has risk factors but fails to make their follow-up visit(s) how do you engage? | |
| - Support materials used with the intervention. | |
| - Documenting and tracking of each member visit. | |
| - Documenting and tracking the members enrolled or eligible for wellness |
and/or disease management.
| - Please provide sample copies of the records used for tracking. |
| - Provide samples of any management reports on intervention activity. |
| - How do you link to on-site or community programs (Employee Assistance Program, Fitness Center, etc.)? |
| - Ensuring confidentiality of member information. |
| - How do you coordinate with off-site specialists involved in the treatment of a member? |
| Measurement Tools & Results: |
| Provide a copy of your quality assurance program. This should include standards and measurement criteria for onsite healthcare activities, costs, outcomes, disease management, member services, member intervention, and educational materials. |
| How would you propose measuring the outcomes and success of the overall program? |
| Describe your standard management reports. Describe your custom reporting capabilities and the associated costs. Please provide a recommendation and examples of reports that you would provide Client. |
| Provide examples of the following: |
| - Onsite clinic activity report |
| - Member participation |
| - Member intervention |
| - Financial summary/savings report |
| - Are management reports available online? |
| Is there an additional cost for any of this reporting? |
| Describe how your Plan specifically evaluates the effectiveness of primary care case management. Include any results of the evaluation as an attachment. |
| Provide all clinical indicators used to track the success of the program and the results, if any, by year since inception of the program. Please include the following: |
| - Program Outcomes |
| - Utilization Measures (list measures) |
| - Member Satisfaction |
| - Changes in the Cost of Care |
| - Productivity (list indicators) |
| - Absenteeism (list indicators) |
| - Disability (list indicators) |
| Describe specifically how records for individuals with both personal health and job injury clinic experience will be managed assuming services provided are only for non-occupational situations. |
| Appointment Scheduling: |
| What is your preferred method for employees to make clinic appointments? |
| Is an electronic web based appointment system included in the price of your services? |
| How do you know if employees would like to be seen and are unable to schedule an appointment? |
| Does your scheduling system allow for same day appointments? |
| How many routine appointments do you offer and how many same day appointments do you offer? |
| How far in the future can employees schedule appointments? |
| How many appointments per day are allocated for preventive care visits, primary care visits and same day episodic visits? (break out for each category) |
| How many minutes are allocated for preventive care visits, primary care visits and same day episodic visits? |
| If you have a separate provider for coaching and DM, how are those appointments made? |
| How many appointments do your clinicians typically see per day? |
| If selected as a finalist, be prepared to provide a demo of your scheduling module. |
| Electronic Medical Record: |
| Do you have an electronic medical record (EMR)? |
| Was the EMR purchased/contracted from an outside developer or did your organization develop it? |
| Is maintenance and EMR updating done by employees of your company or by a contracted organization? |
| Can historical medical and pharmacy claims be loaded into the EMR? |
| Does the EMR connect with other systems used in conjunction with the onsite clinic (i.e. wellness platform)? |
| Can EMR data be sent to a third party (i.e. biometric data)? |
| How do employees get access to view their medical record? |
| Who owns the medical information connected with the operation of the clinic? What procedures are in place to provide this information to another party, if any, should your agreement with the Company be terminated? |
- If our partnership is terminated what provisions do you have to transport/transfer records? Formatting ? Cost?
- What procedures do you have if an employee wishes to have a copy of their medical record?
- What format does your EMR require in order to transfer information into your system? Compatibility with other systems such as EPIC? Cost?
| Medical Oversight: |
| Who provides medical oversight of the clinic? |
| Is this individual an employee of your organization? |
| How do you assess the qualifications of the person that will provide medical oversight? |
| Describe your process for medical oversight of the clinical providers in the clinic. |
| How many hours/week does this individual spend in clinical oversight? |
| How does the employer interact with the person providing medical oversight for the clinic? |
| How do clinic personnel interact with the person providing medical oversight? |
| What is the role of your Medical Director? |
| What indemnification do you provide for malpractice? |
| Outline the process for allowing the current staff to interview/be hired for the clinic. |
| If selected, would you be able to commit to retain current staff at current/competitive compensation levels? |
| Quality Monitoring: |
| Who monitors the quality of your clinical staff? |
| Describe the quality control process? |
| What is the frequency of quality review? |
| Does your EMR provide clinical evidence based guidelines for the provider? |
| If yes, what guidelines do you use? Are they proprietary or do you use another established protocol? |
| How do you know if clinicians are following the electronic clinical guidelines? |
| What happens if anything when a clinician does not follow the clinical guidelines? |
| How do you report clinical quality to the employer? Please provide a sample of the report. |
| Outline your process for how your onsite clinic would dispense prescriptions. |
| Interaction with Community Physicians: |
| If an employee has a primary care provider outside of the clinic, how will clinic providers (coaches, DM, physician, RN) communicate and coordinate care for the employee? |
| Do you have an electronic mechanism to communicate with community providers? Do you share the EMR data with the provider? |
| If a referral is made to a physician specialist in the community, do you have a process for following this care? If so, please share this process. |
| How do you identify what specialist in the community to use when a clinic patient needs to see a specialist? |
| Do you utilize any cost or quality tools to develop community referrals? |
| Is this referral documented in the EMR? |
| Do you have a way to track if an employee follows through on a referral? |
| What can you report on a regular basis about these referrals? |
| Preventive Care/Immunizations: |
| Please list all standard preventive care examinations/procedures that your organization will offer in an onsite clinic. |
| What source do you use to determine age and gender appropriate preventive screening tests? |
| For standard preventive care examinations/procedures your clinicians provide, please provide data indicating how many of each have been provided in clinics you operate. |
| Please list vaccinations that will be offered in the clinic. |
| Are the cost of vaccinations included in this proposal or is it an additional cost to the employer? |
| Provide your current cost for flu shots (approximately 400 are administered in the clinic currently) |
| Lab Services: |
| What lab services can you provide in the clinic? |
| Can biometric screenings be completed in the clinic during employee visits? |
| What tests are included in the standard biometric screening panel? Can the testing panel be adjusted? |
| If cotinine is NOT included, can it be added? Can the cost be included in the screening package? |
| Is your product electronically linked with a national lab vendor for electronic ordering of lab tests? |
| Is your product electronically linked with a national lab vendor so results are electronically sent to the EMR? |
| If a laboratory specimen is sent to an outside lab, how is it transported to the outside lab or pathologist? |
| How are the fees for lab tests paid when the specimen is sent to an outside lab? |
| Disease Management: |
| What Disease Management (DM) programs/services do you provide? |
| Do you have any formal programs centered around specific diseases/conditions (e.g. diabetes, musculoskeletal, etc) |
| If yes, please list out the programs and what conditions are addressed |
| How are members identified and targeted for disease management? |
| What software/systems are used to determine prevalence of chronic conditions? |
| How does your product determine if participants are compliant with their chronic disease care? |
| How do your providers assess gaps in care and what are they doing to help close these gaps? |
| If evidence based guidelines are utilized, are these embedded in your electronic medical record? |
| If evidence based guidelines are utilized, please list the source of these evidence based guidelines. |
| How does your clinician identify what employees have chronic disease? |
| Does your technology stratify members by severity of illness or risk? Please provide reports outlining the risk stratification grouping that determine individuals that will be outreached by the clinician. |
| If you outreach for DM please outline the process in detail (including outreach criteria, number of outreach attempts, how outreach is provided, etc.). |
| How do you define engagement in DM? |
| What is the typical frequency of contact with employees that are enrolled in the DM program? |
| What percent of those who qualify for DM do you estimate would engage in the 1st year? 2nd Year? 3rd year? |
| Please provide reporting or data to show outcomes achieved from your DM programs. |
| Virtual Capabilities |
| Do you have the ability to offer visits virtually? |
| What are the standard hours of your virtual offering? |
| Does the onsite staff perform the virtual visits? |
| Do you offer virtual visits through staff not specifically hired for the onsite clinic? |
| If yes, please describe how this works |
| What types of services can you offer virtually (assuming a face to face visit is not required)? |
| Urgent care services (yes/no)? |
| Primary care services (yes/no)? |
| Condition management (yes/no)? |
| Behavioral health (yes/no)? |
| If yes, is virtual behavioral health dependent on Pella staffing for behavioral health? |
| What other services can you offer virtually? |
| Are virtual appointments scheduled the same way as in person appointments? |
| For locations with smaller populations, can you utilize either kiosk or remote monitoring tools to facilitate virtual visits? |
| If yes, please describe your capabilities |
| Program Integration, Implementation, & Deployment: |
| What promotional materials are included in this proposal for promoting the launch/re-branding of the clinic? |
| What support is available for ongoing promotions and employee communications? |
| Please provide examples of communication materials/plans for kick off and ongoing communication. |
| For services outlined in this proposal, does your organization need historical medical and pharmacy claims data? |
| Describe how historical medical and pharmacy claims data is utilized? |
| Do you currently or have you in the past received claims data from BCBS (Wellmark) and ESI? |
| Can your organization push clinic claims data with CPT4, ICD9, ICD10 codes to the medical and pharmacy carriers? |
| How does your system integrate with the employer's EAP program? |
| Does your organization currently provide data to Lockton's Infolock® data warehouse? |
| Please describe your clinic and information technology (web-portal) security protocols. |
| Outline best practices established for integration with the clients other vendor partners including medical carriers health coaches and non vendor staff. |
| Please provide a sample implementation and launch plan which represents a January 2026 go-live date. |
| Staffing: |
| How many practitioners, nurses, management staff, etc. do you propose? |
| Do you find more effective results from physician staffing vs. physician extender staffing? |
| What backgrounds do they proposed staff typically have? |
| What other business do you have in Iowa or the surrounding areas that could fill in for holidays, vacations, etc.? |
| How will you manage the services chosen by Client including managing and supervising the medical personnel in charge of the clinic? |
| How will you go about choosing the personnel to staff the clinic and what is the process for evaluating their qualifications? |
| Will you allow Client to be part of the interview process for clinical staff? |
| What is your process for replacing clinic staff should they terminate? |
| What was your average 5 year turnover as it relates to onsite clinic staff? |
| Does your organization apply for in network status with the major carriers in the market? (Cigna, Blue Cross Blue Shield, United Healthcare and Aetna) - The City currently has BCBSOK |
| Miscellaneous: |
| Please outline how you determine who to refer patients to? |
| Do you have clinics with Behavioral Health Services? Are they your own providers or do you work in tandem with the EAP? |
| Final Message: |
| Please describe your key differentiators and your approach to patient management. |
Additional Medical Questions Please Confirm Your Ability to Either Order or Administer the Following Tests: (place an X in the appropiate field)
| Test | Can Order Test | Can Administer |
| Audiometry Test | ||
| CBC | ||
| CMP | ||
| Chest Xray | ||
| Echo | ||
| EKG | ||
| Flu Shot | ||
| Hearing Test | ||
| HEB B TITER | ||
| HEP B #1 | ||
| HEP B #2 | ||
| HEP B #3 | ||
| HEP B BOOSTER | ||
| HEP C | ||
| HIV | ||
| LEAD | ||
| LIPID | ||
| Occult Blood Test | ||
| Post Accident Urine Drug Screen/Breath Alcohol testing | ||
| PARA SCHL UDS | ||
| Pre Employment Urine Drug Screens | ||
| Physical Exam | ||
| PSA | ||
| RABIES TITER | ||
| RANDOM Breath Alcohol Test DOT | ||
| RANDOM Urine Drug Screen DOT | ||
| SPIROM | ||
| STRESS | ||
| TITER | ||
| TSPOT | ||
| VISION |
&P &"Garamond,Italic"2007 Lockton Companies, LLC
Onsite Clinic Pricing Grid
| Chart A: On-Site Clinic Services | |||||||||||||||
| Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | |||||||||||
| Population that will have access to clinic: | Employees and Dependents | Employees and Dependents | Employees and Dependents | Employees and Dependents | Employees and Dependents | ||||||||||
| How long are your proposed fees guaranteed: | |||||||||||||||
| Break Down of Clinic Costs | |||||||||||||||
| Implementation Fee | |||||||||||||||
| Initial Set-Up and Clinic Outfitting Cost (assuming client provides the physical space for the clinic) | |||||||||||||||
| Annual administration fee | |||||||||||||||
| Staffing Fees (separate out staffing costs from benefits costs) | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 | ||||||||||
| Clinic Hours | 40 hours per week | 40 hours per week | 40 hours per week | 40 hours per week | 40 hours per week | ||||||||||
| Assumed weeks per year | 52 weeks per year | 52 weeks per year | 52 weeks per year | 52 weeks per year | 52 weeks per year | ||||||||||
| # of Staff | Expected Annual Salary | Expected Benefits Cost | # of Staff | Expected Annual Salary | Expected Benefits Cost | # of Staff | Expected Annual Salary | Expected Benefits Cost | # of Staff | Expected Annual Salary | Expected Benefits Cost | # of Staff | Expected Annual Salary | Expected Benefits Cost | |
| Annual Physician Salary | |||||||||||||||
| Annual Nurse Practitioner Salary | |||||||||||||||
| Annual Licensed Vocational Nurse Salary | |||||||||||||||
| Annual Medical Assistant Salary | |||||||||||||||
| Annual Front Office Assistant Salary | |||||||||||||||
| Estimated Cost of Benefits (All Staff) | |||||||||||||||
| Estimated Cost of Temporary Staff Needed | |||||||||||||||
| TOTAL | ENTER ESTIMATED TOTAL | ENTER ESTIMATED TOTAL | ENTER ESTIMATED TOTAL | ENTER ESTIMATED TOTAL | ENTER ESTIMATED TOTAL |
| Miscellaneous Fees/Expenses (provide an annual estimate) | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 |
| Computer Supplies | |||||
| Contract Labor | |||||
| Delivery | |||||
| Drug Cost | |||||
| Dues, Subscriptions & Books | |||||
| Education Conference | |||||
| Equipment Rental | |||||
| Immunizations / Vaccinations | |||||
| Information System Support | |||||
| IT Analytics | |||||
| Janitorial Services | |||||
| Lab Fees | |||||
| Medical Supplies | |||||
| Medical Waste | |||||
| Minor Equipment | |||||
| Office Supplies | |||||
| Permits, Licenses & Fees | |||||
| Professional Fees - Other | |||||
| Professional Liability Insurance | |||||
| RCM Encounter Fees | |||||
| Telephone/Connectivity | |||||
| Travel | |||||
| Utilities and Trash | |||||
| Other Miscellaneous Fees (please outline and explain if applicable) | |||||
| Additional Costs – Please outline any additional costs not provided above | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 |
| Total Estimated Costs - Mandatory Services |
| Total Estimated Costs - Optional Services* |
| Pricing Assumptions / Caveats: |
| Please list all assumptions and caveats of your fee proposal. |
| Please list all services accounted for in the annual administration fee |
| *Optional Services are services that the client could add, but is not required to for running a clinic |
&7Company Name &7&P &7Lockton Companies
Top 10 Labs Pricing Grid
| Provide current pricing/associated cost per lab: | Pass Through Cost (per lab draw) |
| Lipid Panel | |
| Cbc With Differential/Platelet | |
| Comprehensive Metabolic Panel | |
| Hemoglobin A1c | |
| Tsh Thyroid Stimulating Hormone With Reflex to T4 | |
| UA Urinalysis Complete | |
| Albumin Creatinine Ratio | |
| Basic Metobolic Panel | |
| Hepatitis Panel | |
| T4, Free |
Top 10 Medication Pricing Grid
| Provide current pricing/associated cost per medication: | |||||||
| 30 day Onsite Dispensed | 90 day Mail Order (if applicable) | ||||||
| Medication | Dosage | Total Cost | Ingredient Cost | Dispensing Fees | Total Cost | Ingredient Cost | Dispensing Fees |
| Rosuvastatin Calcium | 5 mg | ||||||
| Fluticasone Propionate | 50 mcg/ 120 doses | ||||||
| Amlodipine Besylate | 5 mg | ||||||
| Metformin HCl | 500 mg | ||||||
| Omeprazole | 20 mg | ||||||
| Levothyroxine Sodium | 12.5 mcg | ||||||
| Lisinopril | 20 mg | ||||||
| Cetirizine HCl | 10 mg | ||||||
| Atorvastatin Calcium | 10 mg | ||||||
| Metoprolol Succinate | 100 mg |
Eligibility Census
| NOTE: Current census of participants eligible for Clinic services. Clinic is located at zipcode 73102. "Subscriber" refers to employee or retiree. | ||||
| Record | DOB | Gender | Zip code | Relationship |
| 1 | 5/09/1984 | M | 73106 | Subscriber |
| 2 | 7/01/1971 | M | 73003 | Subscriber |
| 3 | 7/08/1973 | F | 73003 | Spouse |
| 4 | 6/19/2002 | M | 73003 | Dependent Child |
| 5 | 6/11/1957 | M | 73114 | Subscriber |
| 6 | 5/20/1960 | F | 73013 | Subscriber |
| 7 | 8/21/1953 | M | 73013 | Spouse |
| 8 | 9/27/1953 | M | 73013 | Subscriber |
| 9 | 10/23/1967 | F | 73013 | Spouse |
| 10 | 10/07/1982 | F | 73099 | Subscriber |
| 11 | 4/16/1997 | F | 73162 | Subscriber |
| 12 | 9/14/1986 | M | 73080 | Subscriber |
| 13 | 5/28/1991 | F | 73080 | Spouse |
| 14 | 9/12/2014 | M | 73080 | Dependent Child |
| 15 | 1/25/2011 | M | 73080 | Dependent Child |
| 16 | 8/04/1976 | M | 73036 | Subscriber |
| 17 | 1/31/1976 | F | 73036 | Spouse |
| 18 | 1/31/2005 | F | 73036 | Dependent Child |
| 19 | 11/30/2007 | F | 73036 | Dependent Child |
| 20 | 8/04/2006 | F | 73036 | Dependent Child |
| 21 | 9/19/1975 | M | 74881 | Subscriber |
| 22 | 6/02/1982 | F | 74881 | Spouse |
| 23 | 10/27/2003 | M | 74881 | Dependent Child |
| 24 | 11/17/1985 | M | 73132 | Subscriber |
| 25 | 9/02/1988 | F | 73132 | Spouse |
| 26 | 8/05/2021 | F | 73132 | Dependent Child |
| 27 | 1/30/1991 | F | 73008 | Subscriber |
| 28 | 1/13/2010 | F | 73008 | Dependent Child |
| 29 | 7/18/1995 | M | 73162 | Subscriber |
| 30 | 8/19/1965 | F | 73170 | Subscriber |
| 31 | 5/27/1981 | F | 73120 | Subscriber |
| 32 | 2/23/1983 | F | 73120 | Spouse |
| 33 | 10/23/1959 | M | 73020 | Subscriber |
| 34 | 4/04/2015 | U | 73105 | Dependent Child |
| 35 | 11/23/1975 | F | 73105 | Spouse |
| 36 | 11/27/2007 | U | 73105 | Dependent Child |
| 37 | 1/28/1997 | F | 73112 | Subscriber |
| 38 | 8/22/2018 | F | 73115 | Dependent Child |
| 39 | 8/13/2015 | M | 73115 | Dependent Child |
| 40 | 12/20/1997 | M | 73026 | Subscriber |
| 41 | 1/14/1963 | M | 73013 | Subscriber |
| 42 | 4/07/1970 | F | 73110 | Subscriber |
| 43 | 12/06/2002 | M | 73110 | Dependent Child |
| 44 | 6/21/1962 | F | 73120 | Subscriber |
| 45 | 11/17/1995 | M | 73179 | Subscriber |
| 46 | 7/16/1997 | F | 73179 | Spouse |
| 47 | 7/08/1981 | F | 73160 | Subscriber |
| 48 | 10/13/2006 | F | 73160 | Dependent Child |
| 49 | 7/24/2008 | M | 73160 | Dependent Child |
| 50 | 3/29/1983 | M | Spouse | |
| 51 | 6/14/2022 | F | 73160 | Dependent Child |
| 52 | 6/11/1978 | F | 73112 | Subscriber |
| 53 | 11/28/2001 | F | 73112 | Dependent Child |
| 54 | 12/15/2006 | F | 73112 | Dependent Child |
| 55 | 11/20/2017 | M | 73112 | Dependent Child |
| 56 | 8/18/1983 | M | 73012 | Subscriber |
| 57 | 3/10/2011 | M | 73012 | Dependent Child |
| 58 | 1/06/2018 | F | 73012 | Dependent Child |
| 59 | 4/30/1957 | M | 74840 | Subscriber |
| 60 | 4/22/1955 | M | 73026 | Subscriber |
| 61 | 4/17/1962 | F | 73026 | Spouse |
| 62 | 10/27/2000 | F | 73026 | Dependent Child |
| 63 | 5/17/2004 | M | 73026 | Dependent Child |
| 64 | 8/29/1963 | M | 73010 | Subscriber |
| 65 | 6/19/1966 | F | 73010 | Spouse |
| 66 | 3/30/1945 | M | 73111 | Subscriber |
| 67 | 4/28/1948 | M | 73131 | Subscriber |
| 68 | 7/30/1948 | F | 73131 | Spouse |
| 69 | 1/17/1954 | M | 73150 | Subscriber |
| 70 | 11/25/1956 | F | 73150 | Spouse |
| 71 | 10/27/1967 | M | 32967 | Subscriber |
| 72 | 3/04/1953 | M | 74848 | Subscriber |
| 73 | 4/24/1952 | F | 74848 | Spouse |
| 74 | 11/05/1954 | F | 73003 | Subscriber |
| 75 | 1/12/1953 | M | 73135 | Subscriber |
| 76 | 12/03/1955 | F | 73135 | Spouse |
| 77 | 3/07/1964 | M | 73025 | Subscriber |
| 78 | 6/02/1950 | M | 73044 | Subscriber |
| 79 | 7/23/1951 | F | 73044 | Spouse |
| 80 | 12/28/1943 | M | 74447 | Subscriber |
| 81 | 7/18/1951 | F | 75862 | Spouse |
| 82 | 6/12/1949 | M | 74427 | Subscriber |
| 83 | 2/16/1943 | M | 78611 | Subscriber |
| 84 | 9/25/1961 | F | 78611 | Spouse |
| 85 | 7/11/1947 | M | 73099 | Subscriber |
| 86 | 11/20/1949 | F | 73150 | Spouse |
| 87 | 11/01/1944 | M | 73160 | Subscriber |
| 88 | 9/21/1948 | F | 73139 | Spouse |
| 89 | 9/30/1952 | M | 73007 | Subscriber |
| 90 | 4/30/1952 | F | 73007 | Spouse |
| 91 | 8/24/1934 | M | 73139 | Subscriber |
| 92 | 9/09/1940 | F | 73139 | Spouse |
| 93 | 1/01/1942 | M | 73121 | Subscriber |
| 94 | 12/28/1960 | F | 73099 | Subscriber |
| 95 | 5/25/1964 | M | 73099 | Spouse |
| 96 | 3/28/1954 | M | 73089 | Subscriber |
| 97 | 10/09/1953 | F | 73089 | Spouse |
| 98 | 6/20/1944 | M | 73160 | Subscriber |
| 99 | 9/23/1946 | F | 73020 | Spouse |
| 100 | 11/19/1971 | F | 73012 | Subscriber |
| 101 | 6/01/1952 | M | 73099 | Subscriber |
| 102 | 4/22/1950 | F | 73099 | Spouse |
| 103 | 3/22/1969 | M | 73034 | Subscriber |
| 104 | 10/07/1973 | F | 73034 | Spouse |
| 105 | 7/21/2011 | F | 73034 | Dependent Child |
| 106 | 12/26/2008 | M | 73034 | Dependent Child |
| 107 | 10/12/1956 | M | 19973 | Subscriber |
| 108 | 5/12/1978 | M | 73065 | Subscriber |
| 109 | 2/27/2005 | F | 73065 | Dependent Child |
| 110 | 5/27/1980 | F | 73065 | Spouse |
| 111 | 9/14/2010 | M | 73065 | Dependent Child |
| 112 | 10/07/1967 | M | 73111 | Subscriber |
| 113 | 11/21/1967 | F | 73111 | Spouse |
| 114 | 8/26/2001 | M | 73111 | Dependent Child |
| 115 | 9/17/1978 | M | 73013 | Subscriber |
| 116 | 8/25/1982 | F | 73013 | Spouse |
| 117 | 9/06/2016 | M | 73013 | Dependent Child |
| 118 | 5/30/2013 | F | 73013 | Dependent Child |
| 119 | 10/16/1972 | M | 73120 | Subscriber |
| 120 | 12/07/1999 | F | 73120 | Dependent Child |
| 121 | 7/06/1971 | M | 73025 | Subscriber |
| 122 | 11/30/2000 | F | 73025 | Dependent Child |
| 123 | 6/09/1978 | F | 73025 | Spouse |
| 124 | 10/26/2003 | M | 73025 | Dependent Child |
| 125 | 3/04/1963 | M | 73013 | Subscriber |
| 126 | 12/19/1962 | F | 73013 | Spouse |
| 127 | 5/01/1962 | M | 73072 | Subscriber |
| 128 | 2/25/1962 | F | 73072 | Spouse |
| 129 | 4/19/1968 | F | 73195 | Subscriber |
| 130 | 7/07/1962 | M | 73141 | Spouse |
| 131 | 9/27/1975 | M | 73099 | Subscriber |
| 132 | 2/02/2005 | M | 73099 | Dependent Child |
| 133 | 9/18/2002 | M | 73099 | Dependent Child |
| 134 | 2/29/1976 | F | 73099 | Spouse |
| 135 | 10/06/1975 | M | 73131 | Subscriber |
| 136 | 9/26/1973 | F | 73131 | Spouse |
| 137 | 9/08/2017 | M | 73131 | Dependent Child |
| 138 | 5/10/2017 | M | 73131 | Dependent Child |
| 139 | 5/29/1968 | M | 73012 | Subscriber |
| 140 | 2/01/1965 | F | 73012 | Spouse |
| 141 | 10/04/1960 | M | 73034 | Subscriber |
| 142 | 1/24/1983 | M | 73159 | Subscriber |
| 143 | 10/28/2005 | M | 73159 | Dependent Child |
| 144 | 5/19/2011 | M | 73159 | Dependent Child |
| 145 | 5/25/2007 | M | 73159 | Dependent Child |
| 146 | 1/01/1985 | F | 73159 | Spouse |
| 147 | 2/14/2003 | F | 73170 | Dependent Child |
| 148 | 12/15/1980 | M | 73112 | Subscriber |
| 149 | 2/17/1968 | M | 73142 | Subscriber |
| 150 | 1/01/1978 | F | 73142 | Spouse |
| 151 | 12/17/2012 | F | 73142 | Dependent Child |
| 152 | 5/06/1962 | M | 73114 | Subscriber |
| 153 | 1/14/2000 | M | 73114 | Dependent Child |
| 154 | 9/27/1970 | M | 73013 | Subscriber |
| 155 | 2/03/2005 | M | 73013 | Dependent Child |
| 156 | 9/12/1971 | F | 73013 | Spouse |
| 157 | 10/20/2001 | M | 73013 | Dependent Child |
| 158 | 5/25/1981 | M | 73064 | Subscriber |
| 159 | 3/03/2006 | F | 73064 | Dependent Child |
| 160 | 6/27/1981 | F | 73064 | Spouse |
| 161 | 1/25/2013 | M | 73064 | Dependent Child |
| 162 | 10/02/2008 | F | 73064 | Dependent Child |
| 163 | 8/22/1961 | M | 73008 | Subscriber |
| 164 | 4/23/1961 | F | 73008 | Spouse |
| 165 | 2/09/1976 | F | 73160 | Subscriber |
| 166 | 4/13/1967 | F | 73084 | Subscriber |
| 167 | 6/15/1961 | M | 73165 | Subscriber |
| 168 | 5/06/1961 | F | 73165 | Spouse |
| 169 | 8/25/1970 | F | 73099 | Subscriber |
| 170 | 4/04/1979 | M | 73099 | Subscriber |
| 171 | 6/23/2009 | M | 73099 | Dependent Child |
| 172 | 6/23/2009 | M | 73099 | Dependent Child |
| 173 | 8/09/1979 | F | 73099 | Spouse |
| 174 | 12/20/1991 | M | 73159 | Subscriber |
| 175 | 7/21/1956 | M | 73120 | Subscriber |
| 176 | 10/15/1989 | F | 73013 | Subscriber |
| 177 | 5/02/2020 | F | 73013 | Dependent Child |
| 178 | 3/13/1989 | M | 73013 | Spouse |
| 179 | 3/11/2013 | M | 73013 | Dependent Child |
| 180 | 11/06/2015 | M | 73013 | Dependent Child |
| 181 | 9/28/1960 | F | 73119 | Subscriber |
| 182 | 12/22/1994 | M | 73107 | Subscriber |
| 183 | 10/22/1980 | F | 73121 | Subscriber |
| 184 | 9/02/2006 | F | 73110 | Dependent Child |
| 185 | 12/01/1968 | M | 73010 | Subscriber |
| 186 | 10/06/1966 | F | 73010 | Spouse |
| 187 | 4/20/1999 | M | 73089 | Subscriber |
| 188 | 12/05/1996 | F | 73170 | Spouse |
| 189 | 12/01/1982 | M | 73135 | Subscriber |
| 190 | 6/17/2018 | F | 73135 | Dependent Child |
| 191 | 1/21/1998 | M | 73099 | Subscriber |
| 192 | 10/10/2021 | F | 73099 | Dependent Child |
| 193 | 2/01/2017 | M | 73099 | Dependent Child |
| 194 | 7/14/1957 | M | 73170 | Subscriber |
| 195 | 4/20/1987 | M | 73012 | Subscriber |
| 196 | 12/12/2008 | M | 73012 | Dependent Child |
| 197 | 11/11/2011 | M | 73012 | Dependent Child |
| 198 | 10/10/2012 | F | 73012 | Dependent Child |
| 199 | 1/23/2023 | F | 73012 | Dependent Child |
| 200 | 12/17/1987 | F | 73012 | Spouse |
| 201 | 11/24/2000 | M | 73120 | Subscriber |
| 202 | 1/22/2006 | M | 73130 | Subscriber |
| 203 | 9/23/1975 | M | 73049 | Subscriber |
| 204 | 7/10/2016 | M | 73049 | Dependent Child |
| 205 | 6/19/2014 | M | 73049 | Dependent Child |
| 206 | 7/01/1984 | F | 73049 | Spouse |
| 207 | 12/28/1998 | M | 73160 | Subscriber |
| 208 | 7/01/2022 | M | 73160 | Dependent Child |
| 209 | 7/26/1976 | F | 73173 | Subscriber |
| 210 | 9/18/2008 | M | 73173 | Dependent Child |
| 211 | 3/20/1956 | F | 73112 | Subscriber |
| 212 | 1/13/1991 | M | 73179 | Subscriber |
| 213 | 2/21/2023 | M | 73179 | Dependent Child |
| 214 | 4/06/2020 | F | 73179 | Dependent Child |
| 215 | 5/22/1991 | F | 73179 | Spouse |
| 216 | 5/05/1967 | F | 73072 | Subscriber |
| 217 | 12/08/1995 | F | 73160 | Subscriber |
| 218 | 3/21/2015 | F | 73084 | Dependent Child |
| 219 | 3/21/2022 | F | 73084 | Dependent Child |
| 220 | 12/18/2016 | F | 73084 | Dependent Child |
| 221 | 3/24/1987 | M | 73170 | Subscriber |
| 222 | 1/11/1988 | F | 73170 | Spouse |
| 223 | 12/23/2014 | M | 73170 | Dependent Child |
| 224 | 11/12/1979 | F | 73139 | Subscriber |
| 225 | 5/18/2000 | M | 73139 | Dependent Child |
| 226 | 8/09/1970 | M | 73139 | Spouse |
| 227 | 4/26/2001 | M | 73139 | Dependent Child |
| 228 | 5/18/1998 | M | 73099 | Subscriber |
| 229 | 1/07/1973 | M | 73162 | Subscriber |
| 230 | 10/02/2013 | F | 73162 | Dependent Child |
| 231 | 7/08/1960 | M | 73132 | Subscriber |
| 232 | 1/12/1964 | F | 73132 | Spouse |
| 233 | 11/13/2005 | F | 73132 | Dependent Child |
| 234 | 11/26/1957 | M | 73020 | Subscriber |
| 235 | 8/12/1959 | F | 73020 | Spouse |
| 236 | 12/01/1961 | M | 73162 | Subscriber |
| 237 | 3/10/1943 | M | 73108 | Subscriber |
| 238 | 2/01/1945 | F | 73108 | Spouse |
| 239 | 8/06/1938 | M | 73135 | Subscriber |
| 240 | 7/19/1943 | F | 73135 | Spouse |
| 241 | 6/28/1959 | M | 73099 | Subscriber |
| 242 | 4/13/1963 | F | 73099 | Spouse |
| 243 | 12/04/1955 | M | 73071 | Subscriber |
| 244 | 11/09/1961 | F | 73071 | Spouse |
| 245 | 10/15/1999 | F | 73071 | Dependent Child |
| 246 | 10/15/1999 | F | 73071 | Dependent Child |
| 247 | 9/25/1937 | F | 73036 | Subscriber |
| 248 | 1/06/1962 | F | 73080 | Subscriber |
| 249 | 7/02/1933 | F | 73162 | Subscriber |
| 250 | 9/22/1964 | M | 73120 | Subscriber |
| 251 | 3/30/1950 | M | 73008 | Subscriber |
| 252 | 3/03/1954 | M | 73038 | Subscriber |
| 253 | 2/20/1947 | F | 73038 | Spouse |
| 254 | 7/08/1953 | F | 73119 | Subscriber |
| 255 | 7/06/1945 | M | 73127 | Subscriber |
| 256 | 5/21/1930 | F | 74501 | Subscriber |
| 257 | 10/06/1952 | M | 73159 | Subscriber |
| 258 | 8/21/1950 | F | 73159 | Subscriber |
| 259 | 7/25/1941 | F | 80247 | Subscriber |
| 260 | 10/16/1956 | M | 74851 | Subscriber |
| 261 | 4/24/1957 | F | 74851 | Spouse |
| 262 | 7/02/1956 | M | 73064 | Subscriber |
| 263 | 9/10/1957 | F | 73064 | Spouse |
| 264 | 2/19/1942 | M | 73159 | Subscriber |
| 265 | 3/26/1954 | M | 73010 | Subscriber |
| 266 | 2/10/1954 | F | 73010 | Spouse |
| 267 | 11/04/1952 | F | 73118 | Subscriber |
| 268 | 8/10/1933 | M | 73112 | Subscriber |
| 269 | 11/10/1956 | F | 75163 | Subscriber |
This is the start of the file's text. The full file is on GovTribe.
File details come from the government source that posted it. Updated .