U.P. Survey Question Title * 1. Please enter contact Name Question Title * 2. Please enter NPI Question Title * 3. Contact Email Address Question Title * 4. Contact Phone Number Question Title * 5. Provider Specialty Type (select all that apply) Ambulance Clinics (RHC, FQHC, LHD, THC) Dental DME Home Health Hospice Hospital - Inpatient Hospital - Outpatient Nursing Facility Private Duty Nursing Vision Other (professional - CMS 1500 billing) Question Title * 6. What type of session do you find most beneficial? (select all that apply) 1 on 1 - Meet with a Medicaid Provider Consultant individually for approximately 30 minutes Group - Specialty specific - Session to cover issues specific to provider specialty (i.e. nursing facility, dental, etc.) Group - General Medicaid information - Session to cover general issues and Medicaid initiatives (i.e. policy updates, ICD-10, ACA, etc.) Other (please specify) Question Title * 7. If you selected Group Session in question #6 would you prefer? PowerPoint Presentation Round Table Discussion Combination of both Question Title * 8. Would you be interested in a CHAMPS Navigational session? Yes No Question Title * 9. Which location(s) would you be most likely to attend? (select all that apply) Baraga Escanaba Iron River Marquette Sault Ste Marie Question Title * 10. Do you have access to a large meeting room that you would be willing to allow Michigan Medicaid to host a session at your location?Please keep in mind that staff from other offices/practices would be attending. Yes No If yes, please enter your location (city) and if there would be a charge for its use. Done