Practice Availability & Services Offered

MAPP has a referral service and we'd like you participate if you wish.  In order to make this as efficient as possible, please complete this survey so we can match the best person for the referral.  This is a confidential survey and only MAPP's Executive Director will use this information.  

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* 1. Demographic Information

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* 2. Are you employed by a hospital or large practice?

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* 3. Are you still practicing?

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* 4. Do you have openings in your practice?

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* 5. What is the best way to contact you to make an appointment?

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* 6. What populations do you treat?

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* 7. What are your clinical speciality areas?

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* 8. Please list any type of insurance you accept:

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* 9. Do you offer telehealth appointments?

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* 10. Is there anything else you'd like to add?

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