Provider Demographics

As a participating plan of the South Carolina Healthy Connections Prime Medicare-Medicaid program, we are required to provide our Healthy Connections Prime Members with access to medical programs and services. We are required to reasonably accommodate enrollees and ensure programs and services are accessible (including physical and geographic access) to individuals with disabilities as they are to individuals without disabilities. Accordingly, we will inform enrollees of a provider's ability to accommodate special needs through the provider directory. Through a system of icons in the provider directory, enrollees will be able to identify specific levels of accommodations at provider sites. Please visit our website and verify that your provider demographics are correct in our online provider at www.firstchoicevipcareplus.com.

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* 1. Practice name:

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* 2. Practice tax ID number:

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* 3. Practice web address:

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* 4. I have confirmed that all provider information (including group name, provider's name, address and phone number) in the online provider directory (accessible from www.firstchoicevipcareplus.com) is correct for all provider's associated with this tax ID number.

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* 5. Provider Fax Number:

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* 6. Individual Completing the Survey:

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* 7. Email Address the office would like to receive electronic communications:

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* 8. Please confirmed the practice hours of operations (click on the opening and closing time for each day.)

  Open Closed Open Closed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

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* 9. Do/Can you provide alternative appointment scheduling for those who need extra time, extended hours or home visits?

  Yes/No
Alternative appointment scheduling
Extended Hours
Home Visits
Not applicable

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* 10. Please list the specific languages spoken by the provider(s) or staff.

 
American Sign Language (ASL)
Arabic
Chinese
French
French-Creole
German
Greek
Italian
Japanese
Korean
Polish
Portuguese
Russian
Spanish
Vietnamese
Not Applicable
Other - Please specify in provider name comment box

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* 11. Do any of the providers in your office have special experience, skill, expertise, or training in treating persons with any of the following?

 
Trauma
Substance Abuse
Physical Disabilities
HIV/AIDS
Serious Mental Illness
Homelessness
Deafness or hard of hearing
Blindness or Visual Impairment
Co-occurring disorders
Not applicable
Other - Please specify in provider name comment box

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* 12. Is your practice location available by public transportation?

 
Bus
Train
Rail
Not Applicable

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* 13. Has the provider or staff completed cultural competency training?

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* 14. Is the provider location ADA compliant for the following?

 
Wide Entry
Wheelchair Access
Accessible Exam Rooms
Accessible Tables
Accessible Lifts
Accessible Scales
Accessible bathrooms including stalls and grab bars
Not applicable

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* 15. Do you accommodate services, teaching materials and documents for individual with learning, intellectual and/or cognitive disabilities?

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* 16. Are printed materials available in alternative formats?

 
Large Print (16 to 18 point font)
Braille
Taped Text
Digital versions of commonly used written materials
Optical Recognition Software
Not applicable

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* 17. Do you provide any of the following accommodations to ensure effective communication with hearing-impairment individuals?

 
Qualified sign language
Written notes between the provider and patient
Computer aided real-time transcription (CART)
Video relay service (VRS)
Assisted listening devices or systems
Closed caption decoders
Access to TTY/TTD line
Not applicable
If you have any questions about this survey, please contact Provider Services at 1-888-978-0862.
Thank you for providing this valuable information.

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* 18. Do you have electronic prescribing capabilities?

T