FIDA Provider Directory Questionnaire

* Company Name :

* DBA :

* Address 1 :

Address 2 :

* City :

* State :

* Zip :

* Phone :

Email Address :

* Please enter your tax ID.

* Include Provider Licensing Information

* What are you business days of operation?

* Are you open on holidays, if so, please indicate which one(s) below

* Are you accepting new patients?

Yes

No

* Do you have any special skill, expertise or training in treating persons with the following conditions? If so, please select which one(s) below

* Indicate your accessibility to individuals with physical disabilities

Wheelchair Access

Accessible Exam Rooms

Accessible Equipment

Other

* Are you accessible by public transportation?

Yes

No

* Indicate whether you support electronic prescribing

Yes

No