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 specialist and behavioral health services to our members, we have developed a short survey to monitor and evaluate member access to specialty and Behavioral Health services.

Please complete the survey 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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