MGFA Partners in MG Care Application Survey

Question Title

* 1. Partner in MG Care Applicant Details

Name *

Practice Name or Company

Mailing Address *

Address 2 *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number

Question Title

* 2. Contact Information for Assistant (If Applicable)

Name

Email Address

Phone Number

Question Title

* 3. What type of provider are you?

Neurologist

Mental Health Professional

Physical Therapist

Surgeon

Other (please specify)

Question Title

* 4. Practice or Company Website

Question Title

* 5. What type of insurance do you accept (if any)?

Medicare

Medicaid

Dual Eligible (Medicare/Medicaid)

Private Insurance

Private Pay

VA Benefits

TRICARE

I don't accept insurance

Other (please specify)

Question Title

* 6. Do you offer a sliding fee scale, indigent care, or financial assistance?

Yes

Question Title

* 7. What services do you or your staff/partners provide at your practice? Please select all that apply.

MG Diagnosis and Second Opinion

Ongoing MG Medical and Symptom Management

MG Research or Clinical Trail Participation

Infusion Services

Pediatric Neurological Care

Counseling

Social Work Services

Care Management

Physical Therapy

Occupational Therapy

Speech and Language Therapy

Cognitive Therapy

Neuro-opthamology

Ophthalmology

Neuromuscular Focus

Pain Management

Mobility Device Assessments

General Medical Care (General Practitioner/Internist)

Nursing Services

SFEMG and Other Diagnostic Testing

Alternative Therapies (Massage, Biofeedback, Wellness Programs, Acupuncture, or Nutrition Counseling)

None of the above

Other (please specify)

Question Title

* 8. What are your hours of operation?

Question Title

* 9. To what extent is your office accessible to people with disabilities?

Wheelchair Accessible

Automatic Doors

Entrance Ramp

Accessible Parking

Elevator Accessible

Accessible Restroom

Office on Ground Floor

Accessible Exam Table

Other (please specify)

Question Title

* 10. Do you or other staff members speak a language other than English?

Yes

If yes, please specify

Question Title

* 11. Approximately how many patients with MG do you see annually?

Question Title

* 12. Do you offer home visits or telemedicine?

Yes

Question Title

* 13. Specialty and Professional Degrees (Please List)

Question Title

* 14. Are you licensed to practice in the state where this practice is located?

Yes

Question Title

* 15. How many hours (approximately) of continued education have you completed in the past 3 years specifically related to MG?

Question Title

* 16. Do you have any MG specific training or certifications?

Yes

Question Title

* 17. Are you board certified or board eligible (if applicable, for physicians only)?

Yes

Not applicable

Question Title

* 18. Do you prescribe treatments as recognized in MG International Consensus Guidelines for Myasthenia Gravis?

Yes

Not applicable

MGFA Partners in MG Care Application

Question Title

* 1. Partner in MG Care Applicant Details

Question Title

* 2. Contact Information for Assistant (If Applicable)

Question Title

* 3. What type of provider are you?

Question Title

* 4. Practice or Company Website

Question Title

* 5. What type of insurance do you accept (if any)?

Question Title

* 6. Do you offer a sliding fee scale, indigent care, or financial assistance?

Question Title

* 7. What services do you or your staff/partners provide at your practice? Please select all that apply.

Question Title

* 8. What are your hours of operation?

Question Title

* 9. To what extent is your office accessible to people with disabilities?

Question Title

* 10. Do you or other staff members speak a language other than English?

Question Title

* 11. Approximately how many patients with MG do you see annually?

Question Title

* 12. Do you offer home visits or telemedicine?

Question Title

* 13. Specialty and Professional Degrees (Please List)

Question Title

* 14. Are you licensed to practice in the state where this practice is located?

Question Title

* 15. How many hours (approximately) of continued education have you completed in the past 3 years specifically related to MG?

Question Title

* 16. Do you have any MG specific training or certifications?

Question Title

* 17. Are you board certified or board eligible (if applicable, for physicians only)?

Question Title

* 18. Do you prescribe treatments as recognized in MG International Consensus Guidelines for Myasthenia Gravis?

Question Title

* 19. Is there anything else that might be helpful for us to know?