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Survey

Please complete all of the questions in this survey so we can process your guide.  Make sure you use proper capitalization and punctuation.  If you have any questions about these questions, please do not hesitate to give us a call.
* Means this is a required field
 
   1.  What is the "Public" name of your business?
(What company name do you use in your marketing, signage, letterhead and other references?)

   2.  Does your company have a different "Legal" name? If so, what is it?

   3.  What is the legal structure of your business?


   4.  In what state was your company legally formed?

   5.  What is the complete STREET address of your PRIMARY location?
(Enter the physical address, including the city, state and zip code.)

   6.  What is the complete STREET address of your affiliate location 1?
(Enter the physical address, including the city, state and zip code.)

   7.  What is the complete STREET address of your affiliate location 2?
(Enter the physical address, including the city, state and zip code.)

   8.  What is the complete STREET address of your affiliate location 3?
(Enter the physical address, including the city, state and zip code.)

   9.  Who is on the governing body of the company?

   10.  What is your primary telephone number

   11.  Please list any persons with a 5% or greater ownership of the company:

   12.  Please type your mission statement in the space below: (if you don't have one, please create one.)
(Your mission statement is a profession of the purpose or meaning you find in the work you do.)

   13.  Who is responsible for the company's Patient Privacy program?

   14.  What is the best telephone number to reach the Privacy Officer?

   15.  On what date (mm/dd/yyyy) did your company adopt its current policy on patient access to protected health information?
(Note: This should be 09/01/2013 or the date of your company's creation, whichever is later.)

   16.  What accounting software do you use in your practice?
(QuickBooks, Peachtree, etc, or "we use an accountant to manage our finances")

   17.  Does your organization provide Therapeutic Footwear items or services?
   18.  Does your organization provide Post Mastectomy services?
   19.  What is the company's guideline for contacting new patients within a certain number of days of patient referral?
(If you do not currently have a policy, please choose from an answer below.)


   20.  If you make specialized emergency equipment available, such as an AED, please provide the name(s) of the person(s) certified in the use of that equipment who are present whenever patients are present.

   21.  Who is responsible for notifying the proper authorities in the event of an emergency at your company?
(You can supply either a specific name or a position.)

   22.  Who is responsible for the company's day-to-day function?

   23.  Who is primarily responsible for the patient intake process?
(Enter either a specific name, or the position.)

   24.  Who should be contacted for "after hours" or emergencies?

   25.  What is the telephone number for "after hours" and emergencies?

   26.  Who should be contacted if the patient has a question about their bill?

   27.  What is the phone number patients should call for billing questions?

   28.  If the patients have any questions, comments or concerns about the care they received, which staff member should they contact?

   29.  What is the phone number patients should call for concerns about their care?

   30.  What is the name of the payment clearinghouse you use?
(For instance, Zirmed)

   31.  Trend tracking and Benchmarking: Please list any tracking and/or benchmarking tools currently used in the business. If none are currently used, these need to be developed and implemented as soon as possible. Please contact Quality Outcomes to sign up for and use the benchmarking tools it has developed in conjuction with OPIE. We have included a default answer that is based on the Quality Outcomes process, for your convenience.

   32.  Who is responsible for the company's Safety Management program?

   33.  Who is responsible for the maintenance of lab and patient equipment?

   34.  Who is responsible for the company's Supplier Compliance program?

   35.  Who is responsible for personnel issues?

   36.  Does your company provide a benefit program?
   37.  If so, please describe the benefit program (you can paste text here):
(Just put summary information here, or None.)

   38.  What is the warranty period that you provide to cover delivered items?
(Please provide your warranty period.)

   39.  Does your company use the OPIE "P&I" service?
  Price Quantity
 Electronic Copy: $1,800.00 1