COVID-19_Healthcare Provider Survey

The Florida Department of Health in Miami-Dade County (DOH-Miami-Dade) is seeking information on healthcare providers efforts to provide COVID-19 screening and testing. This information will only be used for planning services.

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* 1. Please provide the following information:

Name of the individual completing this form: *

Agency/Institution/Medical Practice name: *

Agency/Institution/Medical Practice phone number:

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* 2. If you are a physician, what is your medical specialty?

Family Medicine

Internal Medicine

Pediatrician

Geriatrician

Other (Include your specialty in the text box below)

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* 3. Are you offering any of the following services (check all that apply)?

a. COVID-19 Screening

b. COVID-19 Testing

c. Telehealth Services

d. Not providing any services listed above

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* 4. If you selected yes for any of the above services, provide the following information for your organization. If no, enter n/a in at least one field.

What is your daily patient capacity for COVID-19 testing?
(Considering availability of PPE)

No. of COVID-19 Testing kits available:

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* 5. Agency/Institution/Medical Practice Address (If services are provided in multiple locations, please provide all service addresses):

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* 6. Is a client required to have medical insurance to access COVID-19 services at your agency?

Yes

Other (please specify)