Enter all service locations and the corresponding office hours specific to the provider identified in this survey. If you are completing this survey for more than one location, please complete each field in full. If you have more than 3 locations, you can complete an additional survey to provide all the necessary information.

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* 1. Enter Today's Date

Date / Time

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* 2. Provider Last Name

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* 3. Provider First Name

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* 4. Provider Middle Initial

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* 5. Provider NPI (10-digit # required)
If you are a non-traditional/waiver provider and do not have an NPI - enter  9999999995)

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* 6. Provider E-mail Address

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* 7. Practice Location 1: Street Address
Include building and/or suite information

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* 8. Practice Location 1: City Name

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* 9. Practice Location 1: State (Abbreviation)

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* 10. Practice Location 1: Zip Code

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* 12. Practice Location 1:
Group Name/Practice Location Name

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* 13. Practice Location 1: Phone Number
Provide phone number members should call to make an appointment

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* 14. Practice Location 1: Start Times

  Closed 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 15. Practice Location 1: End Times

  Closed 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 16. Practice Location 1: Comments
Use this area to provide any additional information you would like to provider about Practice Location 1 (e.g. handicap access, public transit, etc.)

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* 17. Practice Location 2: Street Address
Include building and/or suite information

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* 18. Practice Location 2: City Name

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* 19. Practice Location 2: State (Abbreviation)

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* 20. Practice Location 2: Zip Code

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* 22. Practice Location 2:
Group Name/Practice Location Name

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* 23. Practice Location 2: Phone Number
Provide phone number members should call to make an appointment

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* 24. Practice Location 2: Start Times

  Closed 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 25. Practice Location 2: End Times

  Closed 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 26. Location 2: Comments
Use this area to provide any additional information you would like to provider about Practice Location 2 (e.g. handicap access, public transit, etc.)

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* 27. Practice Location 3: Street Address

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* 28. Practice Location 3: City Name

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* 29. Practice Location 3: State (Abbreviation)

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* 30. Practice Location 3: Zip Code

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* 32. Practice Location 3:
Group Name/Practice Location Name

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* 33. Practice Location 3: Phone Number
Provide phone number members should call to make an appointment

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* 34. Practice Location 3: Start Times

  Closed 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 35. Practice Location 3: End Times

  Closed 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 36. Location 3: Comments
Use this area to provide any additional information you would like to provider about Practice Location 3 (e.g. handicap access, public transit, etc.)

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