Healthcare Provider Information Form Survey

Question Title

* 3. Would you like OSP materials sent to your office? (e.g., patient facing postcards, posters etc.)

Yes

Question Title

* 4. What materials would be of most interest to you? Check all that apply.

Postcards for patient self-referral

Brochures for patient self-referral

Posters for waiting/clinical rooms

Tear-away notepad for patient self-referral

Information sheet for health care provider referral

Question Title

* 5. Please include your address for OSP materials to be delivered.

	1	2	3	4	5
Patient has been referred to program (if PCP is not the referral source).	Patient has been referred to program (if PCP is not the referral source). 1	Patient has been referred to program (if PCP is not the referral source). 2	Patient has been referred to program (if PCP is not the referral source). 3	Patient has been referred to program (if PCP is not the referral source). 4	Patient has been referred to program (if PCP is not the referral source). 5
Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving).	Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 1	Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 2	Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 3	Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 4	Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 5
Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service.	Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 1	Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 2	Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 3	Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 4	Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 5
Patient has exited the program.	Patient has exited the program. 1	Patient has exited the program. 2	Patient has exited the program. 3	Patient has exited the program. 4	Patient has exited the program. 5
OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient).	OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 1	OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 2	OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 3	OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 4	OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 5

Patient has been referred to program (if PCP is not the referral source).

Patient has been referred to program (if PCP is not the referral source). 1

Patient has been referred to program (if PCP is not the referral source). 2

Patient has been referred to program (if PCP is not the referral source). 3

Patient has been referred to program (if PCP is not the referral source). 4

Patient has been referred to program (if PCP is not the referral source). 5

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving).

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 1

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 2

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 3

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 4

Patient’s triage decision following assessment (notifying you of which OSP service they will be receiving). 5

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service.

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 1

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 2

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 3

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 4

Patient is transferring from one OSP service to another – usually a ‘step-up’ from a less intensive service to a more intensive service. 5

Patient has exited the program.

Patient has exited the program. 1

Patient has exited the program. 2

Patient has exited the program. 3

Patient has exited the program. 4

Patient has exited the program. 5

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient).

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 1

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 2

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 3

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 4

OSP is not suitable for the patient (usually sent with recommendations for other services and when possible we will redirect the patient). 5

Healthcare Provider Information Form

Stay in the know!

Question Title

* 1. First & Last Name

Question Title

* 2. Email Address

Question Title

* 3. Would you like OSP materials sent to your office? (e.g., patient facing postcards, posters etc.)

Question Title

* 4. What materials would be of most interest to you? Check all that apply.

Question Title

* 5. Please include your address for OSP materials to be delivered.

Question Title

* 6. We are reviewing how the OSP program communicates with PCPs and referral sources.

Please assign a level of importance (5 being most important and 1 being least important) to each of these communication points during the client’s journey in OSP.

Healthcare Provider Information Form

Stay in the know!

Question Title

* 1. First & Last Name

Question Title

* 2. Email Address

Question Title

* 3. Would you like OSP materials sent to your office? (e.g., patient facing postcards, posters etc.)

Question Title

* 4. What materials would be of most interest to you? Check all that apply.

Question Title

* 5. Please include your address for OSP materials to be delivered.

Question Title

* 6. We are reviewing how the OSP program communicates with PCPs and referral sources. Please assign a level of importance (5 being most important and 1 being least important) to each of these communication points during the client’s journey in OSP.

* 6. We are reviewing how the OSP program communicates with PCPs and referral sources.

Please assign a level of importance (5 being most important and 1 being least important) to each of these communication points during the client’s journey in OSP.