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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:
(Required.)
Name of the individual completing this form:
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Agency/Institution/Medical Practice name:
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Agency/Institution/Medical Practice phone number:
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)?
(Required.)
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.
(Required.)
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):
(Required.)
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6.
Is a client required to have medical insurance to access COVID-19 services at your agency?
(Required.)
Yes
No
Other (please specify)
Current Progress,
0 of 6 answered
