Name of Organization * Street Address * City, State * Zipcode * Primary Contact * Title * Phone Number * Email Address * Type of Organization * Business/Purchaser Health Coalition Employer Other type of purchasing or advocacy organization If you answered other to the previous question, please explain: State the region(s) or state(s) covered by your coalition. * State the region(s) or state(s) you are applying to cover in your capacity as a Regional Leader * Please note that only one regional leader is designated for each territory Health plan activity in your market * Aetna Anthem BlueCrossBlueShield Cigna UnitedHealthcare Other Number of Hospitals in your Market: * 1-10 10-25 25-100 100+ Why are you interested in becoming a Regional Leader? * Can you confirm that your organization is not a hospital, pharmaceutical company, or health plan and that your organization is not deriving more than 30% of revenue from health? * Yes No Can you confirm that the majority of your board members are affiliated with employers or purchasers (this includes public and private sector employers or other purchasing entities such as Taft-Hartley trusts that are not deriving more than 30% of their revenue from health care)? * Yes No Please submit a list of your coalition's board members below: * Please type your name below to confirm your organization has reviewed the responsibilities and benefits of participation as a Leapfrog Regional Leader and if accepted, you are prepared to commit to the duties of a Leapfrog Regional Leader * Submit
