Thank you for your interest in providing healthcare services to people living with MS. Within this form you can provide information for up to 3 healthcare providers per office. The information provided, after being reviewed and approved, will be added to our database for information and referral purposes. Answer fields will expand to accommodate any typed answers. Please return this form using the contact information provided on page 5.
GENERAL INFORMATION
Practice/Company Name:Please indicate practice type: Individual Company or Organization (employed by/part of)
Primary street address:
City: / State: / Zip:
Phone number: / Fax number:
Company website: / Company email address:
Hours of operation:
Please indicate the extent to which your office is accessible to people with disabilities. Check all that apply.
wheelchair accessible automatic doors entrance ramp accessible parking
parking assistance (valet) office on ground floor accessible restroom elevator accessible (if above ground flr)
Do you or other staff members speak a language other than English?
Yes No If yes, please list languages:
Please list any eligibility requirements for your services (e.g. referral requirements, age limits, income limits, counties, etc.).
Additional office location(s) and contact information:
SERVICES PROVIDED AT YOUR PRACTICE
Please the box next to the service type and provide details to elaborate on services if necessary. Check all that apply.
Behavioral /or cognitive therapyDetails: / Ongoing MS medical symptom management
Details:
Complementary alternative medicine*
Details: / Pain management
Details:
Counseling (individual or group counseling)
Details: / Patient family education about MS
Details:
General medical care (general practitioner)
Details: / Physical therapy
Details:
Gynecological services
Details: / Social work services
Details:
MS diagnosis second opinion
Details: / Speech language therapy
Details:
Neuropsychological or cognitive evaluation & treatment
Details: / Teaching for self-catheterization
Details:
Nutrition services
Details: / Teaching for self-injection
Details:
Obstetric services
Details: / Urological services
Details:
Occupational therapy
Details: / Other services Please describe:
*e.g. acupuncture, massage, etc. Please describe services.
PROVIDER 1 INFORMATION
Please only answer questions that apply to you.
Provider Name: / Medical Specialty:Phone:
Can this number be available to the public? Yes No / Email:
Can this email be available to the public? Yes No
Approximate number of unique patients with MS seen annually:
Approximate number of continuing education hours specifically related to MS in last two years:
Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? Yes No
Do you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) Yes No
If so, please describe:
Please list any hospital/clinic or medical group affiliations:
Please indicate the types of insurance accepted at your facility/organization. Check all that apply.
Medicare Medicaid Dual Eligible (Medicare/Medicaid)
Private Insurance Private Pay VA Benefits TRICARE
Other (please describe):
Do you offer a sliding fee scale? Yes No / Do you offer indigent care? Yes No
Do you offer financial assistance? Yes No / Do you make home visits? Yes No
Please list any licenses, credentials, professional organizations, or relevant specialized training:
In which states do you hold a license? / What is/are your professional degree(s)?
Please describe any post-graduate training you have had in MS?
Are you Board Certified? No Yes Medical specialty board:
If not, are you Board Eligible? Yes No
Do you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS?
(e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) Yes No
Have you been involved in MS clinical trials or other MS research? Currently involved Previously involved No
Please describe research, if applicable:
FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*
Do you carry at least $1 million/$3 million malpractice coverage? Yes No Comments:
If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?
By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.
PRINTED NAME: / TITLE/POSITION:
PROVIDER 2 INFORMATION
**If you have no more providers at your facility, go to page 6. Please only answer questions that apply to you.
Provider Name: / Medical Specialty:Phone:
Can this number be available to the public? Yes No / Email:
Can this email be available to the public? Yes No
Approximate number of unique patients with MS seen annually:
Approximate number of continuing education hours specifically related to MS in last two years:
Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? Yes No
Do you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) Yes No
If so, please describe:
Please list any hospital/clinic or medical group affiliations:
Please indicate the types of insurance accepted at your facility/organization. Check all that apply.
Medicare Medicaid Dual Eligible (Medicare/Medicaid)
Private Insurance Private Pay VA Benefits TRICARE
Other (please describe):
Do you offer a sliding fee scale? Yes No / Do you offer indigent care? Yes No
Do you offer financial assistance? Yes No / Do you make home visits? Yes No
Please list any licenses, credentials, professional organizations, or relevant specialized training:
In which states do you hold a license? / What is/are your professional degree(s)?
Please describe any post-graduate training you have had in MS?
Are you Board Certified? No Yes Medical specialty board:
If not, are you Board Eligible? Yes No
Do you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS?
(e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) Yes No
Have you been involved in MS clinical trials or other MS research? Currently involved Previously involved No
Please describe research, if applicable:
FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*
Do you carry at least $1 million/$3 million malpractice coverage? Yes No Comments:
If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?
By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.
PRINTED NAME: / TITLE/POSITION:
PROVIDER 3 INFORMATION
**If you have no more providers at your facility, go to page 6. Please only answer questions that apply to you.
Provider Name: / Medical Specialty:Phone:
Can this number be available to the public? Yes No / Email:
Can this email be available to the public? Yes No
Approximate number of unique patients with MS seen annually:
Approximate number of continuing education hours specifically related to MS in last two years:
Are you interested in being listed in our Speakers Bureau and considered for future speaking opportunities? Yes No
Do you carry any form of professional liability (or comparable) insurance? (Answers for NMSS internal use only.) Yes No
If so, please describe:
Please list any hospital/clinic or medical group affiliations:
Please indicate the types of insurance accepted at your facility/organization. Check all that apply.
Medicare Medicaid Dual Eligible (Medicare/Medicaid)
Private Insurance Private Pay VA Benefits TRICARE
Other (please describe):
Do you offer a sliding fee scale? Yes No / Do you offer indigent care? Yes No
Do you offer financial assistance? Yes No / Do you make home visits? Yes No
Please list any licenses, credentials, professional organizations, or relevant specialized training:
In which states do you hold a license? / What is/are your professional degree(s)?
Please describe any post-graduate training you have had in MS?
Are you Board Certified? No Yes Medical specialty board:
If not, are you Board Eligible? Yes No
Do you prescribe FDA approved disease modifying medications, when appropriate, in the treatment of MS?
(e.g. , Avonex, Betaseron, Copaxone, Extavia, Gilenya, Novantrone, Tysabri, and/or Rebif) Yes No
Have you been involved in MS clinical trials or other MS research? Currently involved Previously involved No
Please describe research, if applicable:
FOR PHYSICIANS ONLY: To ensure the protection of people with MS and the National MS Society from a professional liability insurance perspective, we require information on malpractice/liability insurance for all potential healthcare provider referral sources. Please note that the answers to the following 2 questions will not be included in the public database and will not be included in referral information. *Please inform the National MS Society of any changes to your malpractice insurance coverage status*
Do you carry at least $1 million/$3 million malpractice coverage? Yes No Comments:
If you do not have a formal medical malpractice insurance policy, what financial provisions have you placed to cover potential third party actions?
By signing this survey intake form, I attest to the accuracy and validity of the information provided and give my permission to the National Multiple Sclerosis Society to review it and to distribute the public information herein, for the sole purpose of providing referrals. *Please see page 5 of this form for additional information about your electronic signature.
PRINTED NAME: / TITLE/POSITION:
Thank you for completing this form! If National MS Society staff members have questions about any of the information provided in this form, please list the name and phone number for the person to contact to get clarification.
PRINTED NAME:PHONE NUMBER/EMAIL:
Please return completed forms by mail, email or fax to:
Greater Delaware Valley Chapter
National MS Society
30 S. 17th Street, Suite 800
Philadelphia, PA 19103
Phone: 215-271-1500
Fax: 215-271-6122
Website: www.nationalMSsociety.org/pae
Email:
Electronic Signature Agreement: By typing your name on this form, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
www.nationalMSsociety.org JOIN THE MOVEMENT 1-800-344-4867
Page 2 of 5 Healthcare Provider Form