Primary Care Provider Survey

The purpose of this survey is to collect information that is used to assess, develop, and manage primary care Health Professional Shortage Areas (HPSAs) in Alaska. HPSA designations identify areas which have a shortage of health care providers and are scored to measure the scope of the shortage. Thirty-six Federal programs use HPSA scores to direct resources such as grants, loan repayment programs, and training to areas with unmet primary care, dental and mental health needs. Accurate information is vital to maintain HPSA scores which reflect the primary care needs in Alaska.

You can help by: completing this survey annually by April 30, 2024, and by contacting us via email when primary care physicians (physical, dental, mental) and certified nurse midwives stop working at your location.

Common programs relying on HPSA designations include:

· National Health Service Corps and Nurse Corps
· SHARP Loan Repayment
· J-1 Visa Waiver
· CMS Medicare Incentive Payment

Please complete a separate survey for each physician working at this practice location for these primary care types:

-Internal Medicine, Family Medicine, Pediatrics, OB/GYN

-General Dentistry, Pediatric Dentistry

-Psychiatry

-Certified Nurse Midwives - This is the only non-physician professional included in this survey.

Medical Practice Information

Practice Name

Street Address

City

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Based on the average number of patients per week at this location, estimate the percentage of patients in the following categories:

What percentage of patients are covered by Medicaid?

What percentage of patients use a sliding fee scale?

What percentage of patients identify as American Indian/Alaskan Native?

What percentage of patience experience homelessness (sheltered or unsheltered; no permanent residence)?

Provider Name

First NameMiddle NameLast Name

National Provider Identifier (NPI)#*

Degree (choose one)

Primary Care Type

Is provider a federal employee?

YesNo

In general, how many hours per week is the provider engaged in patient care at this location, including time working on a patient's behalf, such as chart work or researching treatment or medications for a patient (do not include administrative, education, or training time)?

Is the provider accepting new patients?

YesNo

Does this provider practice at additional locations?

YesNo

If this provider practices at additional locations, please complete a separate survey for each location.

Are there other Providers at this location to include in this survey?

YesNo

If there are other Providers at this location, please click the button labeled "Fill another form for a different provider at this location" on the Thank You page after you submit this form.

Name of Person Completing the Survey

Title of Person Completing the Survey

Phone Number of Person Completing the Survey

Please enter a valid phone number.

Email Address of Person Completing the Survey

example@example.com

Additional Comments:

For questions contact Katie Reilly or Judy Holland at doh.dph.primarycareoffice@alaska.gov.

If you have additional providers at this location, please follow the link provided on the Thank You page. Medical Practice Information will pre-populate to simplify this task.

I am ready to submit this form. (We apologize for this annoying extra step but it is necessary to prevent accidental submission of incomplete forms by the untimely use of the "enter" key.)*

Yes

Alaska Primary Care, Dental, and Mental Health Provider Survey