Appointment Access Survey As an active provider for Alliant Health Plans, we are asking for your help in completing the Provider Survey for the plan year 2024. We ask that you answer these questions with the most accurate information. Step 1 of 6 - Welcome 16% Name / Tax InformationSelect Your Specialty(Required) Behavioral Health OB-GYN Oncology Practice/Group Name(Required) Tax ID(Required) Service LocationAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhonePlease check all the types of clinicians in practice at this location. Select all that apply.(Required) Practitioners with prescribing authority Practitioners without prescribing authority None of the Above Provide the number of clinicians in practice in each categoryProvide the number of psychiatrists and nurse practitioners with prescribing authority(Required)Provide the number of all other licensed clinicians without prescribing authority(Required)Provide the Number of Physicians(Required)Please enter a number greater than or equal to 0.Provider the Number of Nurse Practitioners and Physician Assistants(Required)Please enter a number greater than or equal to 0.Provide the number of Nurse Midwives(Required)Please enter a number greater than or equal to 0.Do you have 3 available appointment times with the next 30 days for a new patient initial visit?(Required) Yes No Do you have 3 available appointment times within the next 30 days for a routine follow-up for an established patient?(Required) Yes No Prescriber Appointment AccessibilityDo you have availability to offer non-life threatening emergency care within 6 hours or do you refer them to the emergency room?(Required) Yes, we have availability to offer non-life threatening emergency care within 6 hours. No, we refer patients to the emergency room. Do you provide urgent care within 48 hours?(Required) Yes No Do you have availability for an initial visit for routine care within 10 business days?(Required) Yes No Do you offer follow-up routine care?(Required) Yes No Non-Prescriber Appointment AccessibilityDo you have availability to offer non-life threatening emergency care within 6 hours or do you refer them to the emergency room?(Required) Yes, we have availability to offer non-life threatening emergency care within 6 hours. No, we refer patients to the emergency room. Do you provide urgent care within 48 hours?(Required) Yes No Do you have availability for an initial visit for routine care within 10 business days?(Required) Yes No Do you offer follow-up routine care?(Required) Yes No Contact InformationWhat is the preferred Medical Record Request Method?(Required) Email Fax Mail Provide the Medical Record Delivery Contact Name(Required) Provide the Medical Record Delivery Contact Phone Number(Required) Provide the Newsletter Recipient Name(Required) Provide the Newsletter Recipient Email(Required) Provide the Newsletter Recipient Fax Number(Required)What is the preferred Newsletter Delivery Method?(Required) Email Fax Mail ConfirmationPlease provide your name(Required) Please provide your email address(Required) Please provide your phone number(Required)By providing your first and last name below you are confirming that you answered to the best of your ability and hold the authority to complete these questions on behalf of your entire practice.(Required) CAPTCHA