Directions :
Survey may take approximately 10 minutes to complete and submit. To ensure optimum user efficiency and time management please read and follow ALL directions.
If time you have alotted is not adequate, there is a "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 of the following apply to you or the dentist (if not please select option 'N/A')?
* 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)
* must provide value
Today M-D-Y
If individual has relocated please input new practice information and email in designated fields below (if information is being filled out by someone other than the practitioner listed)
County of Practice
* must provide value
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
e.g. Davidson
Month, Day, and Year of Birth:
* must provide value
Today M-D-Y Please write in MM/DD/YYYY format (e.g. 01/01/1972)
License Number
* must provide value
Please do not include preceeding letters or zeros
NPI Number
* must provide value
10-digit number issued by CMS
What is your Degree?
* must provide value
Doctor of Medicine in Dentistry Doctor of Dental Surgery Other (please indicate below)
e.g. DDS
Other
* must provide value
2 Check all Specialties that Apply:
What is the youngest patient that you will treat?
* must provide value
What is the oldest patient you will treat?
* must provide value
3 Indicate Your Residency Status:
* must provide value
U.S. Citizen
Permanent Resident
Serve Under a H1B
Serve Under a J-1 Visa
4 Practice and Dental Provider Information
Dental Provider First Name:
* must provide value
Dental Provider Middle Name:
Dental Provider Last Name:
* must provide value
None Jr. Sr. II III IV V VI VII VIII IX X
Practice Name:
* must provide value
If practice does not have name put "None" in text box
Practice Street Number:
* must provide value
e.g. 710
Practice Street Name:
* must provide value
e.g. James Robertson
Practice Street Suffix:
* must provide value
NONE ANX AVE BND BLVD BYPASS CTR CIR CT DR FT HWY LN PKY PIKE PL PLZ RD SQ ST TER TPKE VLY WAY
e.g. PKY
N E S W SE SW NE NW None
e.g. North, Southeast, West
City:
* must provide value
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):
* must provide value
Email Address again for verification (one that is still accessible to you in the event of job relocation):
* must provide value
Please check to make sure that your email in both fields above are entered correctly.
* must provide value
View equation
The two email addresses provided are not the same. Please verify your email address.
6 How many hours per week do you devote to treating patients at this location?
Do not include hospitals, nursing homes or similar sites.
* must provide value
hrs/week
9 Do you serve under contract with either the Federal NHSC (National Health Service Corps) Scholarship or NHSC Loan Repayment Programs?
* must provide value
Yes
No
12 Do you currently have TennCare patients in your practice?
* must provide value
Yes
No
Indicate the approximate percentage of your patients who use TennCare to pay for services.
* must provide value
Click Cursor Outside of Field When Finished
13 Do you accept NEW TennCare patients?
* must provide value
Yes
No
14 Are you currently accepting new patients into your practice (other than TennCare)? *
* must provide value
Yes
No
15 Do you offer a published sliding fee scale based on income or patient's ability to pay for services?
* must provide value
Yes
No
Indicate the approximate percentage of your patients who pay for services based on a sliding fee scale.
* must provide value
Click Cursor Outside of Field When Finished
16 Do you practice at another site?
* must provide value
Yes
No
How many different practices are you employed with in total?
* must provide value
1 2 3 4 5 6 7 8 9 10
Please indicate the proper number of alternate locations that you are employed by.
Please fill out the required information for this practice location (if applicable). Please also be sure to fill out an additional survey for each practice site.
Please complete a separate survey for each practice site. Also, an additional link to complete a new survey will be provided after you submit this survey. 17 DENTISTS ONLY: Do you have any dental auxillaries (e.g. dental hygienists or dental assistants) that assist you (the dentist) in providing care at your practice?
* must provide value
Yes
No
Total number of Dental Hygienists that assist you (the dentist) in providing care at your practice?
* must provide value
0 1 2 3 4 5 6 7 8 9 10
TOTAL number of hours/week worked in an average week by ALL Dental Hygienists for this Practice Site ?
For example: If one hygienist works 20 hours weekly and another works 30 hours a week, the total hours would be 50.
* must provide value
Click Cursor Outside of Field When Finished
Total number of Dental Assistants that assist you (the dentist) in providing care at your practice?
* must provide value
0 1 2 3 4 5 6 7 8 9 10
TOTAL number of hours/week worked in an average week by ALL Dental Assistants for this Practice Site ?
For example: If one assistant works 20 hours weekly and another works 30 hours a week, the total hours would be 50.
* must provide value
Click Cursor Outside of Field When Finished
Please complete a separate survey for each practice site. Also, an additional link to complete a new survey will be provided after you submit this survey.
Please complete a separate survey for each practice site. Signature of person completing this census form verifying that ALL information is correct:
* must provide value
MUST CLICK "ADD SIGNATURE" IN GREEN ABOVE
Name of person submitting survey:
* must provide value
(type name in text box above)
Title of person submitting survey:
* must provide value
(e.g. Dr., Mr., Ms. or Mrs.)
Date of completion and submission:
* must provide value
Today Y-M-D Click button labeled "Today"
Please complete a separate survey for each practice site. Also, an additional link to complete a new survey will be provided after you submit this survey.
Directions Reminder :
If time you have alotted is not adequate, there is a "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.