Healthcare Provider Survey

HEALTHCARE PROVIDER SURVEY

Provider Identification

NPI Number:

Tax Identification Number (EIN/SSN):

Administrative & Clinical Contacts

Practice Characteristics

Practice Type: Primary Care Specialty Facility (Clinic/Hospital) Other

Number of Providers: MD/DO   NP/PA   Other

Hours, Access & Capacity

After-Hours Coverage: Yes No

Accepts Walk-in Patients: Yes No

Telemedicine Services Available: Yes No

Patient Populations & Access

Accepting New Patients: Yes No

Special Programs or Populations Served (select):

Medicare beneficiaries
Medicaid beneficiaries
Pediatrics
Geriatrics
Behavioral health
Palliative / hospice

Services, On-site Capabilities

On-site Services: Laboratory Imaging/X-ray Pharmacy Infusion/Therapy Minor procedures/surgery

Insurance & Billing

Accepted Payer Types (select all that apply):

Medicare
Medicaid
Commercial Plans
Self-pay / Sliding scale
Workers' Compensation

Quality, Safety & Compliance

Accreditation Status:

Infection Control Policy in Place: Yes No

Referrals, Authorizations & Communication

Prior Authorization Required for Specialty Services: Yes No

Privacy & HIPAA Acknowledgment

The undersigned certifies that the information provided on this survey is true and accurate to the best of their knowledge. The provider maintains policies and procedures to comply with federal and state privacy and security laws governing protected health information, including administrative, technical, and physical safeguards appropriate to the size and scope of the organization.

I acknowledge that survey responses may be used for contracting, credentialing, network directory, and quality assessment purposes, and that proprietary or sensitive performance information will be handled in accordance with applicable privacy protections.

Acknowledgment I certify that this practice complies with privacy and information security requirements and that I am authorized to submit this information.

Representative Patient Example (Optional)

Provide a representative patient record to illustrate typical care (optional).

Date of Birth:

Representative Patient - Insurance & Medical History

Policy Number:

Certifications, Attestation & Authorization Period

By signing below, the authorized representative certifies under penalty of perjury that the information provided in this survey is true, complete, and current. The provider agrees to notify requesting parties of material changes affecting any information in this survey within a commercially reasonable time. Submission of this survey does not constitute a binding contract unless a separate agreement is executed by the parties.

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