Directions : ALL Save and Return " option located at the end of the survey. If you utilize this option, please retain a copy of your "return code ", as you will need it later to finish completing your survey without starting over. Do ANY
* must provide value
N/A
Retired
Deceased (if filing for the deceased)
Practice Closed
Relocated
Approximate date when the individual _____________ ? (e.g. died, retired, or relocated)
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Today M-D-Y
If individual has relocated please substitute new practice information and email in designated fields (if information is being filled out by someone other than the practitioner listed) County of Practice
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Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Davidson Decatur Dekalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon McMinn McNairy Macon Madison Marion Marshall Maury Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson
License Number
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NPI Number
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10-digit number issued by CMS
1 What is your Degree?
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Doctor of Osteopathy (D.O.)
Medical Doctor (M.D.)
Physician Assistant
Certified Nurse Midwife
Acute Care NP
Family NP
Pediatric NP
Women's Health NP
Other (please indicate below)
Other
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2 Indicate the percentage of time spent in each specialty:
*DO NOT use percentage sign for values* A) Family Practice (If value is "0" input a zero here)
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If value is none, input a zero.
B) General Practice (If value is "0" input a zero here)
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If value is none, input a zero.
C) Pediatrics (If value is "0" input a zero here)
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If value is none, input a zero.
D) General Internal Medicine (If value is "0" input a zero here)
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If value is none, input a zero.
E) Public Health (If value is "0" input a zero here)
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If value is none, input a zero.
F) Obstetrics (If value is "0" input a zero here)
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If value is none, input a zero.
G) Gynecology (If value is "0" input a zero here)
* must provide value
If value is none, input a zero.
H) OB/GYN (If value is "0" input a zero here)
* must provide value
If value is none, input a zero.
I) Other (If value is "0" input a zero here
* must provide value
If value is none, input a zero.
Total Percentage of Practice (will be automatically calculated in text box to the right. Click Outside of field to retrieve calculation)
View equation Total NOT to exceed 100%
The percentages do not add up to 100. Percentages DO NOT add up to 100. Please check your previous entries above. Be sure that the 'Total Percentage of Practice' field equals 100
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View equation You CANNOT type in this text box
Is the total of the percentages of your practice equal to 100?
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Yes No
Click "Yes" if total is equal to 100.
3 Indicate Your Residency Status:
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U.S. Citizen
Permanent Resident
Serve Under a H1B
Serve Under a J-1 Visa
4 Practice and Clinician Information
Clinician First Name:
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Clinician Last Name:
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None Jr. Sr. II III IV V VI VII VIII IX X
Practice Name:
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IF PRACTICE DOES NOT A HAVE NAME CHOOSE "NONE" IN TEXT BOX
Practice Street Number:
* must provide value
e.g. 704
Practice Street Name:
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e.g. James Robertson | DO NOT INPUT STREET SUFFIX OR PO BOX INFORMATION HERE
Practice Street Suffix:
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NONE ANX AVE BND BLVD BYPASS CTR CIR CT DR FT HWY LN PKY PIKE PL PLZ RD SQ ST TER TPKE VLY WAY
IF PRACTICE ADDRESS DOES NOT HAVE A SUFFIX CHOOSE "NONE" IN TEXT BOX
N E S W SE SW NE NW None
e.g. North, Southeast, West
City:
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Business Phone:
* must provide value
Business Phone Extension:
If applicable please enter your extension
Email Address (one that is still accessible to you in the event of job relocation):
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5 Facility type: Check all that apply.
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6 How many hours per week do you provide direct patient care at this practice site? Do not include on call, hospital or nursing home rounds, drug rehab centers, jail, emergency room shifts, or similar sites.
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hrs/week
7 Do you render care to your patients while they are hospitalized? That is, do you both admit your patients to the hospital and provide some of their care while they are hospitalized, rather than having a physician on the hospital staff follow?
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Yes
No
Indicate the average number of hours per week spent with hospitalized patients:
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8 Do you work in a Medical Residency Program?
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Yes
No
Are you a:
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Faculty
Resident
9 Do you serve under contract with either the Federal NHSC Scholarship or NHSC Loan Repayment Programs?
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Yes
No
10 Do you provide Pediatric care (general, routine) to 0-17 year olds? Do not include pregnant teens or family planning.
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Yes
No
Percent of practice:
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Drag bar to desired response
11 Do you provide prenatal ONLY services?
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Yes
No
Percent of practice:
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Drag bar to desired response
Do you provide prenatal AND delivery services?
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Yes
No
Percent of practice:
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Drag bar to desired response
12 Do you currently have TennCare patients in your practice?
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Yes
No
Indicate the approximate percentage of your patients who use TennCare to pay for services.
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Drag bar to desired response
13 Do you accept NEW TennCare patients?
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Yes
No
14 Are you currently accepting new patients into your practice (other than TennCare)? *
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Yes
No
15 Do you offer a published sliding fee scale based on income or patient's ability to pay for services?
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Yes
No
Indicate the approximate percentage of your patients who pay for services based on a sliding fee scale.
* must provide value
Drag bar to desired response
17 Do you practice at another site?
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Yes
No
Please complete a separate survey for each practice site. A new survey will be started after you submit this survey. Do you have other providers at this location for which we have no data?
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Yes
No
Signature of person completing this census form verifying that ALL information is correct:
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MUST CLICK "ADD SIGNATURE" IN GREEN ABOVE
(type name in text box above)
Title:
* must provide value
Position of Person filling form
Date of completion and submission:
* must provide value
Today Y-M-D
Directions Reminder : Save and Return " option located at the end of the survey. If you utilize this option, please retain a copy of your "return code ", as you will need it later to finish completing your survey without starting over.
Submit
Save & Return Later