Americans with Disabilities Act (ADA) Attestation

Americans with Disabilities Act (ADA) Survey

The Americans with Disabilities Act (ADA) and Ohio Administrative Code (OAC) 3781.111 require providers 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 for the Medicaid and MyCare Ohio programs.

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:

Tax ID # or SSN:

Service Location Street Address:

City, State, Zip Code:

Phone Number:

Email Address:

Question Title

* 2. If you are an office-based provider, please check the applicable box next to each standard below and have the designated representative review and return the attestation to Molina Healthcare.

If you are NOT an office-based provider, please skip this question and move to question 3.

	Yes	No
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.	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	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. No
Building has automatic entry option or alternative access method.	Building has automatic entry option or alternative access method. Yes	Building has automatic entry option or alternative access method. No
Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the wheelchair and/or scooter to maneuver.	Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the wheelchair and/or scooter to maneuver. Yes	Building has elevator for public use (if building is multi-leveled). Elevator has enough room for the wheelchair and/or scooter to maneuver. No
Restroom is equipped with large stall and safety bars or other reasonable accommodations.	Restroom is equipped with large stall and safety bars or other reasonable accommodations. Yes	Restroom is equipped with large stall and safety bars or other reasonable accommodations. No
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.	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	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. No
At least one exam room can accommodate patients with physical and non-physical disabilities.	At least one exam room can accommodate patients with physical and non-physical disabilities. Yes	At least one exam room can accommodate patients with physical and non-physical disabilities. No
Signage and way finding is clear (e.g., color, symbol signage, and braille).	Signage and way finding is clear (e.g., color, symbol signage, and braille). Yes	Signage and way finding is clear (e.g., color, symbol signage, and braille). No
Doors to access building, office, and patient rooms are at least 32 inches wide.	Doors to access building, office, and patient rooms are at least 32 inches wide. Yes	Doors to access building, office, and patient rooms are at least 32 inches wide. No
The exam table moves up and down to make it easier to get on and off whether standing or using a wheelchair or scooter.	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	The exam table moves up and down to make it easier to get on and off whether standing or using a wheelchair or scooter. No
Diagnostic equipment can accommodate patients with various disabilities.	Diagnostic equipment can accommodate patients with various disabilities. Yes	Diagnostic equipment can accommodate patients with various disabilities. No
The scale is able to accommodate a wheelchair or scooter.	The scale is able to accommodate a wheelchair or scooter. Yes	The scale is able to accommodate a wheelchair or scooter. No

Question Title

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

Name:

Title:

Date:

Question Title

* 4. Provider service locations that attest to being ADA compliant or have received an in-office assessment and determined to be ADA compliant will be published as such in the Molina Medicaid and MyCare Ohio Provider Directories.

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. If you are an office-based provider, please check the applicable box next to each standard below and have the designated representative review and return the attestation to Molina Healthcare.If you are NOT an office-based provider, please skip this question and move to question 3.

Question Title

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

Question Title

* 2. If you are an office-based provider, please check the applicable box next to each standard below and have the designated representative review and return the attestation to Molina Healthcare.

If you are NOT an office-based provider, please skip this question and move to question 3.