Appointment Access Survey

Name / Tax Information

Select Your Specialty(Required)

Behavioral Health

OB-GYN

Oncology

Practice/Group Name(Required)

Tax ID(Required)

Service Location

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone

Please 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 category

Provide 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 Accessibility

Do 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 Accessibility

Do 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 Information

What 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

Confirmation

Please 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)

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Name / Tax Information

Service Location

Provide the number of clinicians in practice in each category

Prescriber Appointment Accessibility

Non-Prescriber Appointment Accessibility

Contact Information

Confirmation

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