1. Please enter the NH License Number assigned to you:
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1 1 Physician Name: Date of Birth: / / 1. Please enter the NH License Number assigned to you: 2. Sex: Male Female digit NPI number: NPI number te: If you do not know your NPI number, please visit to locate it. 4. Are you Hispanic/Latino? 5. Race: (Select all that apply) White; Black or African American; Amer. Indian or Alaska Native; Asian ( Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other ); Native Hawaiian or Other Pacific Islander ( Guamanian or Chamorro, Samoan, Native Hawaiian, Other ) 6. Do you speak another language other than English in your clinical practice? 6a. If yes, what language(s)? (Select all that apply) Spanish, Portuguese, French, German, Other European, Arabic, Chinese, Other East Asian, Hindi, Other South/Southeast Asian, American Sign Language, Other
2 2 7. Which best describes your current practice status in NH? (Select one) te: Remainder of survey pertains only to providers engaged in full/part time clinical practice in NH Full/Part time clinical practice at one or more locations in NH (Select this option if you work more than 2 scheduled hours per week/8 hours per month.) Clinical work as a Locum Tenens at one location for one year or longer If you did not check one of the two boxes above, please check the appropriate box below and skip the remainder of the survey Clinical work as a Locum Tenens for less than one year at one location Infrequent clinical practice (less than 2 scheduled hours per week/8 hours per month) Medical Administrative/Legal services ONLY Clinical teaching/clinical research ONLY Other work using medical license/training clinical or medical related work within NH t currently working; If checked: Unemployed/Looking On extended leave Other Retired 8. Where did you graduate from medical school (name of school, state)? 9. Year you graduated from medical school: 10. Additional training information: te: Your principal specialty is the specialty you currently spend the most time practicing. Completed Accredited Residency Program/Fellowship? Principal Specialty ; State Secondary Specialty (If applicable) Tertiary Specialty (If applicable) ; State ; State 11. Do you currently hold a waiver for the prescription of buprenorphine? 11a. If yes, are you currently prescribing at the patient limit for this medication? 12. Are you a foreign citizen currently in the US on a work Visa?
3 3 13. Are you currently obligated under the J-1 Visa Waiver Program to work at your clinical practice(s) in NH? 14. Are you currently an obligated provider under the National Health Service Corps program (scholarship or loan repayment)? te: These are programs that cover medical education costs or offer loan repayment in return for working in a federally designated shortage area for a specified period of time. 15. Did you live or work in NH prior to receiving your NH license? 16. How many years have you practiced clinical medicine in NH, as a physician? years 17. Do you expect that you will be practicing medicine in NH 5 years from now?, at about the same level I m currently working, but I expect to increase my hours, but I expect to reduce my hours, but I expect to be practicing in another state, I do not plan to practice medicine 5 years from now 18. How many total hours per week do you typically spend providing clinical medicine across all service locations (i.e. locations with scheduled services of at least 2+ hours per week)? te: Clinical services include direct patient care, as well as any administrative activities related to charting, billing for services, and participation in clinical team activities. It does not include time spent on managerial and oversight activities of the organization or clinical team. (hours per week)
4 4 NH PRACTICE SITE QUESTIONS The following questions should be completed for each location at which you routinely practice medicine (i.e. at least 2+ hours of scheduled services per week). te: If you are a telemedicine provider, please provide the address in which you are stationed, not for which you provide care. If you provide only telemedicine for multiple locations, enter Telemedicine for the site name. Before completing, copy pages 3-5 for each site at which you practice. 19. Practice Name: Practice Phone: ( ) - Extension: Practice Physical Street Address: Practice City: Zip: Practice Mailing Address (if different): Mailing Address City: Mailing Address Zip: digit organizational NPI number organizational NPI number te: If you do not know your NPI number, please visit to locate it. 21. Please identify (with an x ) the specialty(ies) that best define your practice, at this site: Specialty #1(Principal); Specialty #2 (Secondary); Specialty #3 (Tertiary) te: Your principal specialty is the specialty that you spend the most time practicing at this site. Area of Practice Principal (select one) Secondary (select one, if applicable) Tertiary (select one, if applicable) Adolescent Medicine Anesthesiology Allergy and Immunology Cardiology Child Psychiatry Critical Care Medicine Dermatology Endocrinology Emergency Medicine Family Medicine/General Practice Gastroenterology Geriatric Medicine Gynecologic Oncology Gynecology Only Hematology & Oncology Hospital Medicine (Hospitalist) Infectious Diseases Internal Medicine (General) Nephrology
5 5 Neurology Obstetrics and Gynecology Occupational Medicine Ophthalmology Otolaryngology Palliative Care Pathology Pediatrics (General) Pediatric Subspecialties Physical Med. & Rehab. Preventive Medicine/Public Health Psychiatry Pulmonology Radiation Oncology Radiology Rheumatology Surgery (General) Surgery Subspecialties Colon and Rectal Neurological Orthopedic Other Surgical Specialties Plastic Thoracic Vascular Other 22. Approximately how many hours per week do you typically spend providing clinical services at this location? The hours should not include time spent admitting, discharging, performing daily rounds on hospitalized patients, on-call, or on corporate/management activities unless you are a Hospitalist. hours/week 23. Check the appropriate box below which best describes your work setting at this location: Hospital/Inpatient/Surgical Center services only (hospitalist, pathology, radiology, ER, surgical center, etc.) Extended/Institutional care only (nursing home/snf, residential treatment, etc.) Substance use disorder treatment centers State/federal prison clinic City/County correctional facility Rehabilitation facility (OT/PT/ST) Corporate/Educational Institution or Veterans Administration (VA) Telemedicine A non-traditional setting (e.g. home care, mobile services, etc.) Other NON-outpatient setting Outpatient/Office-based setting (none of the above describes this location)
6 6 24. Is this location an outpatient/office facility owned by a hospital system? te: Private/Stand-alone practices renting space from a hospital should answer '.' 25. Does this location participate in any of the following federal programs? te: Participation in these programs requires formal application and acceptance. Specific definitions apply. Please read the following before indicating participation in any of these programs: "Federally Qualified Health Center" (FQHC) is an official federally designated status for non-profit organizations receiving ongoing federal grant support under Section 330 of the Public Health Service Act. "Rural Health Clinic" (RHC) is an official federally designated status granted to specific primary care service delivery locations in rural areas. RHCs receive enhanced Medicaid and Medicare reimbursement. Do not indicate RHC status if you indicated participation in the FQHC program above. federal program participation at this location Federally Qualified Health Center Federally certified Rural Health Clinic 26. Approximately what percentage of the hours at this address are spent providing each of the following categories of care: (Total must equal 100%) a. Primary Medical Care % te: Primary care includes the initial assessment (first contact) and primary diagnosis of undifferentiated disease, primary treatment of acute conditions, and ongoing management of chronic illness. It also encompasses the performance of health promotion, disease prevention, health maintenance, counseling, and patient education activities, as well as advocating for the patient and coordinating the use of the entire health care system to benefit the patient. Specialties outside of Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology, and General Practice are typically not considered to deliver primary medical care. b. Specialty Care/Procedures % c. Mental Health/Substance Abuse Care % (not incidental to primary medical care) 27. Do you accept NH Medicaid as a form of payment at this location (and accept payment from this payer)?
7 7 28. Is a formal sliding fee discount policy offered at this location? te: Sliding fee discount policies (or sliding fee scales) are based upon federal poverty guidelines, and patient eligibility is determined by annual income and family size. These scales are established to ensure that a non-discriminatory, uniform, and reasonable charge is consistently and evenly applied. This does not include standard, discounted rates for everyone set by the facility or negotiated reductions granted on a caseby-case basis. There must be a sliding fee schedule posted in the waiting room. 28a. If yes, approximately what percentage of visits do you provide on a sliding fee discount basis? % (Enter a number between 1 and 100) 29. Are you currently accepting new patients at this location? N/A (not a primary location for patient intake from the general population) 30. Are there routine (non-urgent) outpatient appointments set at this location? 30a. If yes, approximately what is the present wait for a routine appointment for: 1) A new patient days (te: If new patients are not currently accepted, enter NA) 2) An established patient days
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