Service Provider Resources Healthcare Professional Service ...



Thank you for your interest in providing healthcare services to people living with MS. Within this form you can provide information for up to 3 healthcare providers per office. The information provided, after being reviewed and approved, will be added to our database for information and referral purposes. Answer fields will expand to accommodate any typed answers. Please return this form using the contact information provided on page 5.GENERAL INFORMATIONPractice/Company Name: Please indicate practice type: FORMCHECKBOX Individual FORMCHECKBOX Company or Organization (employed by/part of)Primary street address:City:State:Zip:Phone number: Fax number: Company website: Company email address: Hours of operation:Please indicate the extent to which your office is accessible to people with disabilities. Check all that apply. FORMCHECKBOX wheelchair accessible FORMCHECKBOX automatic doors FORMCHECKBOX entrance ramp FORMCHECKBOX accessible parking FORMCHECKBOX parking assistance (valet) FORMCHECKBOX office on ground floor FORMCHECKBOX accessible restroom FORMCHECKBOX elevator accessible (if above ground flr)Do you or other staff members speak a language other than English? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please list languages:Please list any eligibility requirements for your services (e.g. referral requirements, age limits, income limits, counties, etc.).Additional office location(s) and contact information:SERVICES PROVIDED AT YOUR PRACTICE Please the box next to the service type and provide details to elaborate on services if necessary. Check all that apply. FORMCHECKBOX Behavioral &/or cognitive therapyDetails: FORMCHECKBOX Ongoing MS medical & symptom managementDetails: FORMCHECKBOX Complementary & alternative medicine*Details: FORMCHECKBOX Pain managementDetails: FORMCHECKBOX Counseling (individual or group counseling)Details: FORMCHECKBOX Patient & family education about MSDetails: FORMCHECKBOX General medical care (general practitioner)Details: FORMCHECKBOX Physical therapyDetails: FORMCHECKBOX Gynecological servicesDetails: FORMCHECKBOX Social work servicesDetails: FORMCHECKBOX MS diagnosis & second opinionDetails: FORMCHECKBOX Speech & language therapyDetails: FORMCHECKBOX Neuropsychological or cognitive evaluation & treatmentDetails: FORMCHECKBOX Teaching for self-catheterizationDetails: FORMCHECKBOX Nutrition servicesDetails: FORMCHECKBOX Teaching for self-injectionDetails: FORMCHECKBOX Obstetric servicesDetails: FORMCHECKBOX Urological servicesDetails: FORMCHECKBOX Occupational therapyDetails: FORMCHECKBOX Other services Please describe:*e.g. acupuncture, massage, etc. Please describe services.Please list anything else you would like us to know about yourself or your business : PROVIDER 1 INFORMATION Please only answer questions that apply to you.Provider Name: Medical Specialty:Phone:Can this number be available to the public? FORMCHECKBOX Yes FORMCHECKBOX NoEmail: Can this email be available to the public? FORMCHECKBOX Yes FORMCHECKBOX No Approximate number of unique patients with MS seen annually:Approximate number of continuing education hours specifically related to MS in last two years:Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? FORMCHECKBOX Yes FORMCHECKBOX NoDo you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) FORMCHECKBOX Yes FORMCHECKBOX No If so, please describe:Please list any hospital/clinic or medical group affiliations:Please indicate the types of insurance accepted at your facility/organization. Check all that apply. FORMCHECKBOX Medicare FORMCHECKBOX Medicaid FORMCHECKBOX Dual Eligible (Medicare/Medicaid) FORMCHECKBOX Private Insurance FORMCHECKBOX Private Pay FORMCHECKBOX VA Benefits FORMCHECKBOX TRICARE FORMCHECKBOX Other (please describe):Do you offer a sliding fee scale? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer indigent care? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer financial assistance? FORMCHECKBOX Yes FORMCHECKBOX No Do you make home visits? FORMCHECKBOX Yes FORMCHECKBOX No Please list any licenses, credentials, professional organizations, or relevant specialized training:In which states do you hold a license?What is/are your professional degree(s)? Please describe any post-graduate training you have had in MS? Are you Board Certified? FORMCHECKBOX No FORMCHECKBOX Yes Medical specialty board: If not, are you Board Eligible? FORMCHECKBOX Yes FORMCHECKBOX NoDo you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS? (e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) FORMCHECKBOX Yes FORMCHECKBOX NoHave you been involved in MS clinical trials or other MS research? FORMCHECKBOX Currently involved FORMCHECKBOX Previously involved FORMCHECKBOX NoPlease describe research, if applicable:FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*Do you carry at least $1 million/$3 million malpractice coverage? FORMCHECKBOX Yes FORMCHECKBOX No Comments:If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.SIGNATURE: DATE: PRINTED NAME:TITLE/POSITION:PROVIDER 2 INFORMATION **If you have no more providers at your facility, go to page 6. Please only answer questions that apply to you.Provider Name: Medical Specialty:Phone:Can this number be available to the public? FORMCHECKBOX Yes FORMCHECKBOX NoEmail: Can this email be available to the public? FORMCHECKBOX Yes FORMCHECKBOX No Approximate number of unique patients with MS seen annually:Approximate number of continuing education hours specifically related to MS in last two years:Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? FORMCHECKBOX Yes FORMCHECKBOX NoDo you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) FORMCHECKBOX Yes FORMCHECKBOX No If so, please describe:Please list any hospital/clinic or medical group affiliations:Please indicate the types of insurance accepted at your facility/organization. Check all that apply. FORMCHECKBOX Medicare FORMCHECKBOX Medicaid FORMCHECKBOX Dual Eligible (Medicare/Medicaid) FORMCHECKBOX Private Insurance FORMCHECKBOX Private Pay FORMCHECKBOX VA Benefits FORMCHECKBOX TRICARE FORMCHECKBOX Other (please describe):Do you offer a sliding fee scale? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer indigent care? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer financial assistance? FORMCHECKBOX Yes FORMCHECKBOX No Do you make home visits? FORMCHECKBOX Yes FORMCHECKBOX No Please list any licenses, credentials, professional organizations, or relevant specialized training:In which states do you hold a license?What is/are your professional degree(s)? Please describe any post-graduate training you have had in MS? Are you Board Certified? FORMCHECKBOX No FORMCHECKBOX Yes Medical specialty board: If not, are you Board Eligible? FORMCHECKBOX Yes FORMCHECKBOX NoDo you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS? (e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) FORMCHECKBOX Yes FORMCHECKBOX NoHave you been involved in MS clinical trials or other MS research? FORMCHECKBOX Currently involved FORMCHECKBOX Previously involved FORMCHECKBOX NoPlease describe research, if applicable:FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*Do you carry at least $1 million/$3 million malpractice coverage? FORMCHECKBOX Yes FORMCHECKBOX No Comments:If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.SIGNATURE: DATE: PRINTED NAME:TITLE/POSITION:PROVIDER 3 INFORMATION **If you have no more providers at your facility, go to page 6. Please only answer questions that apply to you.Provider Name: Medical Specialty:Phone:Can this number be available to the public? FORMCHECKBOX Yes FORMCHECKBOX NoEmail: Can this email be available to the public? FORMCHECKBOX Yes FORMCHECKBOX No Approximate number of unique patients with MS seen annually:Approximate number of continuing education hours specifically related to MS in last two years:Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? FORMCHECKBOX Yes FORMCHECKBOX NoDo you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) FORMCHECKBOX Yes FORMCHECKBOX No If so, please describe:Please list any hospital/clinic or medical group affiliations:Please indicate the types of insurance accepted at your facility/organization. Check all that apply. FORMCHECKBOX Medicare FORMCHECKBOX Medicaid FORMCHECKBOX Dual Eligible (Medicare/Medicaid) FORMCHECKBOX Private Insurance FORMCHECKBOX Private Pay FORMCHECKBOX VA Benefits FORMCHECKBOX TRICARE FORMCHECKBOX Other (please describe):Do you offer a sliding fee scale? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer indigent care? FORMCHECKBOX Yes FORMCHECKBOX No Do you offer financial assistance? FORMCHECKBOX Yes FORMCHECKBOX No Do you make home visits? FORMCHECKBOX Yes FORMCHECKBOX No Please list any licenses, credentials, professional organizations, or relevant specialized training:In which states do you hold a license?What is/are your professional degree(s)? Please describe any post-graduate training you have had in MS? Are you Board Certified? FORMCHECKBOX No FORMCHECKBOX Yes Medical specialty board: If not, are you Board Eligible? FORMCHECKBOX Yes FORMCHECKBOX NoDo you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS? (e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) FORMCHECKBOX Yes FORMCHECKBOX NoHave you been involved in MS clinical trials or other MS research? FORMCHECKBOX Currently involved FORMCHECKBOX Previously involved FORMCHECKBOX NoPlease describe research, if applicable:FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*Do you carry at least $1 million/$3 million malpractice coverage? FORMCHECKBOX Yes FORMCHECKBOX No Comments:If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.SIGNATURE: DATE: PRINTED NAME:TITLE/POSITION:Thank you for completing this form! If National MS Society staff members have questions about any of the information provided in this form, please list the name and phone number for the person to contact to get clarification.PRINTED NAME: PHONE NUMBER/EMAIL: Please return completed forms by mail, email or fax to:Greater Delaware Valley ChapterNational MS Society30 S. 17th Street, Suite 800Philadelphia, PA 19103Phone: 215-271-1500Fax: 215-271-6122Website: paeEmail: pae@Electronic Signature Agreement: By typing your name on this form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. ................
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