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1. CONTACT INFORMATION

Thank you for your participation in MSD's Voluntary Initiative Program (VIP) to join the network of Physicians, Allied Health Practitioners and Ancillary Service Providers across the state servicing patients enrolled in the state's Health Care Connection (HCC) program.  
Please answer this questionnaire completely. You may contact us to make changes at any time as needed by calling MSD at 302-366-1400 or email to: info@medsocdel.org

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* 1. Please choose the answer that best fits, I am a

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* 2. Name of Practice/Organization

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* 3. Your full name and credentials

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* 4. Email Address

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* 5. Please choose the most appropriate answer

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* 6. Medical Specialty or Types of goods/services being offered

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* 7. Practice Status

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* 8. Please provide the full name, credentials, specialty, individual NPI number and email contact for any additional  physicians or providers who are also enrolling as part of your practice to the VIP network.

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* 9. Primary Practice Location Address/Phone (Skip to Q20 if a business offering goods/services)

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* 10. Primary Practice Location Fax number

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* 11. Do you see patients at additional locations?

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* 12. Please list the addresses and phone & fax numbers for all additional locations where you would see HCC patients.

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* 13. Mailing Address

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* 14. Who should we contact for VIP related inquiries (billing, scheduling, etc)

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* 15. Does your practice have any bilingual staff? If so, what language(s)?

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* 16. Are you a current member of the Medical Society of Delaware (MSD)?

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* 17. If you are not currently a MSD member, are you interested in membership?

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* 18. Are you a State Loan Repayment Program (SLRP) recipient?

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* 19. Do you have a J-1 visa sponsorship? After answering, please proceed to Q22

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