Medicus Integra Intake Form

A tool to initiate your organization’s journey toward cultivating a culture of well-being for physicians and APPs.

Please complete this form after reviewing the Medicus Integra “Must Haves” and meeting with a member of the Coalition team. This information ensures we are aligned on expectations and fully prepared for a successful evaluation process.

Organization name

Organization Type

Main Facility City

Main Facility State

Affiliated Health System

(if applicable)

Number of Facilities Included in Survey Scope

Total Number of Physicians & APPs at These Facilities

Total Number of Staff (clinical and non-clinical)

Approximate Annual Patient Volume (system-wide)

Section 2: Primary Contact

First name

Last name

Title/Role

(e.g., CMO, CWO, VP of Physician Engagement)

Phone

Are you a Member of the Coalition for Physician & APP Well-Being?

How did you first learn about Medicus Integra?

Choose all that apply.

Section 3: Additional Stakeholders Involved

Stakeholder 1 Name

First/Last Name

Stakeholder 1 Title

Stakeholder 2 Name

First/Last Name

Stakeholder 2 Title

Stakeholder 3 Name

First/ Last Name

Stakeholder 3 Title

Stakeholder 4 Name

First/Last Name

Stakeholder 4 Title

Section 4: Current Well-Being Landscape

What are the top three factors contributing to well-being at your organization?

What are the top three barriers or challenges to well-being?

What formal well-being programs, initiatives, or policies currently exist?

(Brief descriptions encouraged)

Where do you see the greatest opportunity for improvement in your system’s culture of well-being?

Section 5: Medicus Integra Readiness

Have you reviewed the “Must Haves” on our website or shared materials?

Yes

Note: "Must Haves" are listed immediately below.

Which “Must Haves” are currently in place?

Physician and APP Well-Being Committee: A dedicated group addressing wellness, burnout, and engagement initiatives.

Leadership Training: Formalized programs to equip physicians as active organizational leaders.

Coaching & Counseling Programs: Facility-sponsored support for addressing burnout and stress.

Bi-Directional Communication Framework: Processes for transparent, two-way communication between staff and leadership.

Collegiality Initiatives: Programs promoting collaboration, mentoring, and trust-building among providers.

Standardized Onboarding: A comprehensive orientation process emphasizing mission, culture, and well-being resources.

Code of Conduct & Follow-Up Process: A written code for professional behavior with clear follow-up protocols for addressing concerns.

(Check all that apply. These items should be in place for survey process to commence.)

What type of support are you looking for at this stage?

Survey & Certification Only

Consulting/Implementation Support

Both

What is your ideal timeline to begin the survey process and (if applicable) receive status?

(Include any hard deadlines or event-driven goals, if applicable)

Section 6: Logistics & Survey Planning

Preferred Survey Submission Start Date:

Address of Primary Survey Location

Preferred Meeting Type

Section 7: Next Steps Acknowledgment

Once this form is submitted, here’s what to expect:

Execution of NDA and financial agreement (if not already completed).
Invoice and payment coordination.
Access granted to secure site for uploading documentation.
Medicus Integra survey checklist and detailed criteria shared.
Schedule planning meetings (typically 30–60 days prior to survey).
Create travel itinerary (if an in-person visit is required).
Review of submitted materials by survey team.
Final logistics and clarification meeting with organization.
Conduct survey.
Receive comprehensive feedback report and recognition status (if applicable).

I confirm acknowledgement of next steps. Thank you.