Please provide as much information as possible. Thank you.
Name of Person Completing Questionnaire Your Phone Your Email
Clinic Name
Address City State Zip County
Contact Person/Dental Director Phone Fax E-mail
Date Clinic was established
Days/Hours of Operation
2. How is your clinic funded and what is the percentage of funds coming from each source? (i.e. federal grant 20%, dental societies 15%, etc.)
3. Indicate the number of providers involved
4. Please provide job titles for the paid personnel/staff (i.e. administrators/directors)
5. Average patients seen per day week month year
5a. What percentage of those patients are: Children (under 18) Adults (18-64) Seniors (65+)
5b. What percentage of patients are enrolled in: CHIP Sliding Scale ACCESS MCO
5c. What percentage of patients come from: Rural backgrounds Urban backgrounds
6. Please estimate the value of dental services provided per day week month year
7. What percentage of treatments provided is preventative care?
8. Please describe the criteria for patient eligibility.
9. Please paste a Mission Statement and/or a Provider Roster for our records (if available).
10. The PDA would appreciate receiving any additional information about this clinic in the space below.
