Americans with Disabilities Act (ADA) Survey

Americans with Disabilities Act (ADA) Survey
Please complete the following survey. Allow 10-15 minutes to complete.
Instructions:
Office Administrators, Managers and Lead Physicians

Virginia Premier Health Plan is obligated by CMS and DMAS to assess each and every one of your practice locations as to compliance requirements of the Americans with Disabilities Act. Please complete and submit this online survey for review and evaluation by Virginia Premier's Compliance Department. Please understand that our assessment of your ADA compliance is required, as your practice provides care for patients who are members of Virginia Premier Health Plan. If we do not hear back from you for each of your office locations (clinical practice locations and separate business office location only if patients come to the business office to transact business), we will follow-up with direct contact through our Provider Service Representatives and paper mailing of the survey. Thank you in advance for your cooperation in completing this survey.
Contact Information:
Please provide the following information:

All fields marked with an asterisk (*) are required.
Group or Solo Practice Name:*
Enter the legal name of your medical practice.
Group or Solo Practice Type:*
Enter the specialty type of your medical practice;
examples: Family Medicine, General Practice, Pulmonology, Internal Medicine, General Surgery, etc.
Group or Solo Practice Address:*
Enter the physical street address for the office, not a post office box, add additional address information in Address Line 2;
example: 1234 Anywhere Street
Suite 101

Street Address Address Line 2 City State ZIP Code
Office Location Phone Number:*
Example: (804)819 - 5151
Fax:
Example: (804)819 - 5151
Email Address*
Enter office contact person’s e-mail address;
example: [email protected]
Group or Solo Practice Tax ID:*
Enter the tax identification number for your practice;
example: 541234567 (Please do not use a dash)
Group or Solo Practice NPI or API
Enter practice’s 10-digit NPI (National Provider Identifier) number;
example: 1234567891
Website Address:
If your practice has its own website, the web address here;
example: http://www.supermedical.com
Designated Contact for Disability Related Issues:*
Enter the contact person’s name in the practice for disability-related issues.
Name of Individual Completing the Survey:*
Enter the person’s name who completed this survey.

Compliance for the Physically Disabled: Equipment
34. If you have a weight scale, is the scale available with a platform to accommodate people in a wheelchair or who are unable to stand w/out assistance?*
Guidance:
There needs to be adequate room adjacent to an adjustable exam table for a mobility device to park to facilitate transfer from device onto the exam table. The minimum amount of space required is 30 inches by 48 inches.
- Yes
- No
- Not Applicable
35. Do you have or can you adapt an exam table for accessible transfers for people who use a wheelchair or are unable without assistance? This may include the use of an adjustable-height table, transfer board, portable lift or a stretcher/gurney.*
Guidance:
1.) Adjustable-height tables must lower to the height of the wheelchair seat, 15 inches or lower from the floor. 2.) A transport board is a simple tool made of a smooth rigid material which acts as a supporting bridge between a wheelchair and another surface, along which the individual slides. 3.) The portable lift base must go under or fit around the exam table for transfer. 4.) Some equipment, including radiologic equipment, lacks the space beneath them necessary for a portable lift. Lifts may not be compatible with some radiological technologies. A stretcher or gurney can be raised or lowered to the height of the exam surface.
- Yes
- No
36. Is the staff trained to help a person with a disability transfer onto the exam table and to operate other accessible equipment?*
Guidance:
Staff members need to know how to operate the accessible equipment, how to assist with transfers and positioning of individuals with disabilities.
- Yes
- No
37. If the facility provides a specialized diagnostic service, is the device used handicap accessible? This may include X-Ray equipment, Ultrasound equipment, mammography equipment, and gynecological examination tables.*
Guidance:
This may include the use of: Mobile Digital X-Rays or Mobile Ultrasound Units. Mammography devices that can be used on a woman in a seated position. A gynecological accessible height exam table with adjustable, padded leg supports, rather than typical stirrups.
- Yes
- No

Providers

Americans with Disabilities Act (ADA) Survey

ADA Survey

Step 1 of 6

Americans with Disabilities Act (ADA) Survey

Instructions:

Office Administrators, Managers and Lead Physicians

Contact Information:

Patient Services:

Provided Translation Services:

Access to Public Transportation Services:

Compliance for the Physically Disabled

Parking:

Guidance:

Guidance:

Guidance:

Exterior Travel Route:

Guidance:

Building Entrance:

Guidance:

Interior Route (From the building entrance to clinic entrance, registration counter, or office area)

Guidance:

Guidance:

Waiting Area:

Guidance:

Guidance:

Restrooms:

Guidance:

Exam Rooms:

Guidance:

Guidance:

Compliance for the Physically Disabled: Equipment

Guidance:

Guidance:

Guidance:

Guidance:

Accommodations for Intellectually and/or Cognitively Disabled

Guidance:

Accommodations for the Blind or Visually Impaired

Guidance:

Guidance:

Accommodations for the Deaf or Hard-of-Hearing

Guidance:

Guidance:

Comments and Concerns: