Provider Special Experience Survey

Special Experience Survey

The Provider Special Experience, related to special experience, skills, expertise, and/or training to better support our members. This survey is to be completed for each individual provider. If you are completing for multiple providers, please email OHAttestationForms@MolinaHealthcare.com for assistance.

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 5-7 minutes to complete. Thank you!

1.Please provide the following information:(Required.)

Group Name:

Tax ID #:

Office Manager:

Physical Address (Include City, State, & Zip Code):

County:

Phone Number:

Fax Number:

Email Address:

Is the office building within walking distance of public transportation (no more than a half mile each way)?

2.Specific Provider Information for Survey Completion:(Required.)

Provider Name:

Provider NPI:

3.NON-Behavioral Health Providers Only (Answer #3 or #4, not both):

Does your office have special experience, skills, expertise, and/or training to better support our members? This is specific to special qualifications, licensing, experience, skill and/or training in treating the following:

5.Submitter Information (Required for Attestation):(Required.)

Name:

Title:

Phone:

Email Address: