NH Healthy Families works to make sure that needed services are available to our members. One of our many goals is to ensure adequate access to healthcare for our members. In an effort to assess the current availability of primary care services to our members, we have developed a short survey to monitor and evaluate member access to PCP services.

Please complete the questions below for each practice location.

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* 1. Your Full Name:

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* 2. Your Title:

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* 3. Location Name:

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* 4. Tax ID Number: (Numeric Only, No Symbols)

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* 5. Number of Providers in Practice: (Numeric Only)

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* 6. Practice Office Manager Name:

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* 7. Practice Phone Number: (Numeric Only, No Symbols)

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* 8. Practice Fax Number: (Numeric Only, No Symbols)

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* 9. Email:

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* 10. Is the location accessible to people with disabilities?

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* 11. Office Hours:

Monday Open
Monday Close
Tuesday Open
Tuesday Close
Wednesday Open
Wednesday Close
Thursday Open
Thursday Close
Friday Open
Friday Close
Saturday Open
Saturday Close
Sunday Open
Sunday Close

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* 12. Are you participating in NH Healthy Families provider network?

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* 13. Are you participating in the Ambetter from NH Healthy Families network?

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* 15. Do you have a process in place to provide  after-hours coverage 24 hours/day, 7 days/week?

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* 16. If yes, is the coverage internal or external?

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* 18. Please describe variations between your office locations related to the survey questions: (If any)

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