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!

Question Title

* 1. Please provide the following information:

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)?

Question Title

* 2. Specific Provider Information for Survey Completion:

Provider Name:

Provider NPI:

Question Title

* 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:

Physical Disabilities

Chronic Illness

HIV/AIDS

Serious Mental Illness

Homelessness

Deafness or Hard-of-Hearing

Blindness or Visual Impairment

Co-ocurring Disorders

Question Title

* 4. 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:

Alcohol/Drug Screening Analysis/Lab Urinalysis

Ambulatory Detoxification

Assessment

Case Management

Crisis Intervention

Individual Counseling

Group Counseling

Induction of Buprenorphine

Injection of Naltrexone, to treat addiction

Intensive Outpatient, to treat addiction

Psychological Testing

Medical Somatic

Community Psychiatric Supportive Treatment

Home Health Services Comprehensive Care Coordination

Injections, long acting antipsychotic medications

Mental Health Assessment

Partial Hospitalization

Pharmacological Management

Psychiatric Diagnostic Interview

Aging

Children, Adolescents, and Young Adults

SPMI

Dual diagnosis, MH/AOD

Developmental Disorders Intellectual Disabilities

Child Welfare

Forensics

HIV/AIDS

Trauma

Domestic Violence

Veterans

Question Title

* 5. Submitter Information (Required for Attestation):

Name:

Title:

Phone:

Email Address:

Provider Special Experience Survey

Special Experience Survey

Question Title

* 1. Please provide the following information:

Question Title

* 2. Specific Provider Information for Survey Completion:

Question Title

* 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:

Question Title

* 4. 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:

Question Title

* 5. Submitter Information (Required for Attestation):

* 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:

* 4. 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: