Member Intake Survey
Please complete the member survey to the best of your knowledge. This will help us in creating a new brochure and the "Members Only" section of our website. If you have any questions, please feel free to reach out to Nicole Stanfield at ncstanfield@medassist.org.
Name of person completing survey.
Organization
Department
If your department is art of a larger organization, please let us know which department.
Organization Phone Number
Website
Hours of Operation
M-F, Weekends, Monthly, etc.
Address
If our organization operates more than one site, please list all addresses.
Address
Add more
Who do you serve?
Select all that apply.
Uninsured
Medicare
Medicaid
Private Insurance
Do patients need to meet qualifications in order to receive services?
Select all that apply.
Must apply for services.
Must be uninsured.
Must meet income requirements.
Must receive Medicaid denial.
We serve all patients regardless of income or insurance status.
What is the income limit?
Ex: 200% FPL
What services and programs do you offer?
Select all that apply. These can be direct or indirect services.
Primary Care
Specialty Care
Choice Senior Care
Health Education
Behavioral Health Services
Diabetes Education Program
Pharmacy Services
Medication Assistance
Dentistry
Vaccinations
Maternal Child Health Program
Substance Use Treatment Services
Pregnancy Resources
Legal Services
Other
What additional services and programs do you offer?
Service/Program
Add more
How do you receive patient referrals?
Self referrals
NC CARE360
Find Help (formerly Aunt Bertha)
Community Resource Hub
My Community
Other
How else do you receive referrals?
Social Media Handles
Be sure to add all handles or links to handles. Facebook, Linkedin, etc.
Add more
Official Logo
If you have updated your logo, please upload it.
Delete all uploads
Choose files or drag here
What CEUs do you or your staff need?
EX: ACHE, CHW, CHES, etc.
Questions, comments, concerns or suggestions?
Feel free to share your thoughts.
Verification
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