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ADA Site Compliance for Illinois Providers
Demographic Information
Please take the time to fill out this 4 page survey on your facility/practice's ADA Site Compliance.
*
1.
Demographic Information
(Required.)
Physician Name
Facility
Address
Suite #
State
Zip Code
Email
Phone Number
*
2.
Please select your Provider Type
(Required.)
Adult Daycare Medicaid
Behavioral Health Provider
Dialysis Centers
Doctor Or Medical Professional
Durable Medical Equipment
Federally Qualified Health Centers
Home Health Agencies
Home Infusion Therapy
Hospital Or Other Facility
Immediate Care Centers
Long Term Services Support
Medical Group Or Other Type
Nursing Facility
Nursing Facility Medicare
Other Healthcare Professional
Primary Care Physician
Prostheses / Orthotics / Pedorthist
Retail Health Clinic
Skilled Nursing Facility
Specialists
Supportive Living Facility
Other (please specify)
*
3.
Provider or facility license, NPI, Medicare, Medicaid, and Tax numbers
(Required.)
Provider / Facility License #
Provider / Facility NPI #
Medicare #
(optional - if not applicable answer "NA")
Medicaid #
Tax ID #
*
4.
Is your location in close proximity to public transportation?
(Required.)
Yes
No
Additional Information
*
5.
Language Capabilities: please select non-English Language(s), including ASL, spoken and/or enter any language(s) not listed in the "other" field.
(Required.)
American Sign Language (ASL)
Spanish
Polish
Chinese
Tagalog
Korean
Arabic
Russian
Italian
Greek
Hindi
No Other Languages
Other language(s) (please specify)
*
6.
Is there a Language Line Interpreter available?
(Required.)
Yes
No
