This free survey is powered by
Create a Survey
Surveys
2014
June
F
FIDA Provider Directory Questionnaire
FIDA Provider Directory Questionnaire
0%
Questions marked with an
*
are required
Exit Survey
*
Company Name
:
*
DBA
:
*
Address 1
:
Address 2
:
*
City
:
*
State
:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
*
Zip
:
*
Phone
:
Email Address
:
*
Please enter your tax ID.
*
Include Provider Licensing Information
*
What are you business days of operation?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
*
Are you open on holidays, if so, please indicate which one(s) below
New Year's Day
Martin Luther King Day
President's Day
Memorial Day
Independence Day
Labor Day
Columbus Day
Thanksgiving Day
Christmas Day
Other
*
Are you accepting new patients?
Yes
No
*
Do you have any special skill, expertise or training in treating persons with the following conditions? If so, please select which one(s) below
Blindness or Visual Impairment
Chronic Illness
Co-occuring Disorders
Deafness or Hard-of-hearing
End Stage Renal Disease
HIV/AIDS
Physical Disabilities
Serious Mental Illness
N/A
Other
*
Indicate your accessibility to individuals with physical disabilities
Wheelchair Access
Accessible Exam Rooms
Accessible Equipment
Other
*
Are you accessible by public transportation?
Yes
No
*
Indicate whether you support electronic prescribing
Yes
No
Loading...
close
Loading...
Close
qpweb1.questionpro.net