KBM Management, Inc. Managed Care Network Evaluation Form
Insured Name:
Insured Location(s)
E-Mail:
Proprietary Network
Anticipated Savings For:
Inpatient Hospital
Outpatient Hospital
Physicians Charges
Physicians Charges
# of Network Hospitals:
# of Network Physicians:
% of Group Participants
National Network
Anticipated Savings For:
Inpatient Hospital
Outpatient Hospital
Physicians Charges
Physicians Charges
# of Network Hospitals:
# of Network Physicians:
% of Group Participants
Other Network
Anticipated Savings For:
Inpatient Hospital
Outpatient Hospital
Physicians Charges
Physicians Charges
# of Network Hospitals:
# of Network Physicians:
% of Group Participants
Signed By:
Date: