Americans with Disabilities Act (ADA) Attestation

Americans with Disabilities Act (ADA) Survey

Dear Contracted Provider: The Americans with Disabilities Act (ADA) require providers to make reasonable access and accommodations for all persons with disabilities. Molina is providing you with the opportunity to self-attest to the below ADA standards in order to verify core elements of ADA compliance.

Please complete the following survey for each service location.

Your feedback is important, and You Matter to Molina! As a valued partner, please complete and submit the survey below. This survey will take approximately 3-5 minutes to complete.

Thank you

Question Title

* 1. * Please provide the following information:

Provider Name:

Service Location
Street Address:

TIN:

NPI:

City, State, Zip Code:

Phone Number:

Email Address:

Question Title

* 2. Building has accessible (handicap) designated parking. Parking spaces are accessible with ramps and curb cutouts between the parking lot, office and at drop off locations.

Yes

N/A

Question Title

* 3. Building has automatic entry option or alternative access method.

Yes

N/A

Question Title

* 4. Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the wheelchair and/or scooter to maneuver.

Yes

N/A

Question Title

* 5. Restroom is equipped with large stall and safety bars or other reasonable accommodations.

Yes

N/A

Question Title

* 6. Waiting room (including furniture) can accommodate patients with physical and non-physical disabilities. The reception and waiting areas have enough room for a wheelchair and/or scooter to maneuver and turn around.

Yes

N/A

Question Title

* 7. At least one exam room can accommodate patients with physical and non-physical disabilities.

Yes

N/A

Question Title

* 8. Signage and way finding is clear (i.e., color and symbol signage).

Yes

N/A

Question Title

* 9. Doors to access building, office, and patient rooms are at least 32 inches wide.

Yes

N/A

Question Title

* 10. The exam table moves up and down to make it easier to get on and off whether standing or using a wheelchair or scooter.

Yes

N/A

Question Title

* 11. Diagnostic equipment can accommodate patients with various disabilities.

Yes

N/A

Question Title

* 12. The scale is able to accommodate a wheelchair or scooter.

Yes

N/A

Question Title

* 13. Written material is compatible with optical needs.

Yes

N/A

Question Title

* 14. Offers TTY/TDD devices for the Deaf and hard of hearing/ qualified American Sign Language (ASL) interpreters.

Yes

N/A

Question Title

* 15. Does your office require assistance to become ADA compliant. If so, please provide contact information below.

Question Title

* 16. *I attest to the best of my knowledge that the above information is true, accurate, and complete.

Name:

Title:

Date:

Question Title

* 17. Provider service locations that attest to being ADA compliant will be published as such in the Molina Healthcare of Michigan Provider Directory.

Please let us know if you have any questions or feedback on this ADA Attestation.

Americans with Disabilities Act (ADA) Attestation

Americans with Disabilities Act (ADA) Survey

Question Title

* 1. * Please provide the following information:

Question Title

* 2. Building has accessible (handicap) designated parking. Parking spaces are accessible with ramps and curb cutouts between the parking lot, office and at drop off locations.

Question Title

* 3. Building has automatic entry option or alternative access method.

Question Title

* 4. Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the wheelchair and/or scooter to maneuver.

Question Title

* 5. Restroom is equipped with large stall and safety bars or other reasonable accommodations.

Question Title

* 6. Waiting room (including furniture) can accommodate patients with physical and non-physical disabilities. The reception and waiting areas have enough room for a wheelchair and/or scooter to maneuver and turn around.

Question Title

* 7. At least one exam room can accommodate patients with physical and non-physical disabilities.

Question Title

* 8. Signage and way finding is clear (i.e., color and symbol signage).

Question Title

* 9. Doors to access building, office, and patient rooms are at least 32 inches wide.

Question Title

* 10. The exam table moves up and down to make it easier to get on and off whether standing or using a wheelchair or scooter.

Question Title

* 11. Diagnostic equipment can accommodate patients with various disabilities.

Question Title

* 12. The scale is able to accommodate a wheelchair or scooter.

Question Title

* 13. Written material is compatible with optical needs.

Question Title

* 14. Offers TTY/TDD devices for the Deaf and hard of hearing/ qualified American Sign Language (ASL) interpreters.

Question Title

* 15. Does your office require assistance to become ADA compliant. If so, please provide contact information below.

Question Title

* 16. *I attest to the best of my knowledge that the above information is true, accurate, and complete.

Question Title

* 17. Provider service locations that attest to being ADA compliant will be published as such in the Molina Healthcare of Michigan Provider Directory. Please let us know if you have any questions or feedback on this ADA Attestation.

* 17. Provider service locations that attest to being ADA compliant will be published as such in the Molina Healthcare of Michigan Provider Directory.

Please let us know if you have any questions or feedback on this ADA Attestation.