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Questionnaire-- Medication-Assisted Treatment (MAT) Services
Provider Information
Individual NPI
Provider Email
Overview of Practice
Type of medical practice:
Please select...
Psychiatrist
Other
Location:
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Rural
Suburban
Urban/Metropolitan
Practice Type:
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Private Practice
Clinic
CMHC
Outpatient
IOP
Other
Number of Prescribers in Practice:
Number of Therapists in Practice:
Do you provide outpatient ambulatory detoxification?
Please select...
Yes
No
Medication Assistance Treatment
Do you provide Medication-Assisted Treatment (MAT) for Opiate Use Disorder (OUD)?
Please select...
Yes
No
Do you provide Medication-Assisted Treatment (MAT) for Alcohol Use Disorder (AUD)?
Please select...
Yes
No
If no, are you interested or do you plan to provide MAT for OUD or AUD in the future?
Please select...
Yes
No
Would you like for us to contact you for further discussion or information?
Please select...
Yes
No
Specific information requested?
Do you exclude any patient populations?
Please select...
No
Pregnant Females
Adolescents
Other
Do you prescribe buprenorphine products?
Please select...
Yes
No
DEA Certificate
Do you prescribe Vivitrol?
Please select...
Yes
No
Do you refer to (Alkermes-sponsored) injection sites?
Please select...
Yes
No
Do you provide Vivitrol injections in office?
Please select...
Yes
No
Do you exclude any medications?
Please select...
Yes
No
If yes, indicate all that apply:
Vivitrol
Do not have a Buprenorphine waiver
Other
If other, please list:
How long do you tend to keep patients on MAT agents for OUD?
How long do you tend to keep patients on MAT agents for AUD?
How do you manage Urine Drug Tests (UDTs)?
How often are patients tested?
Do you use a dipstick assessment before sending presumptive positive UDTs for quantitative analysis?
Please select...
Yes
No
Do you routinely send all UDTs for quantitative assessments?
Please select...
Yes
No
Do you have a written UDT Policy and Procedure for patients to review?
Please select...
Yes
No
What do you do when members have a positive UDTs?
How do you utilize the Prescription Drug Monitoring Program (PDMP)?
When do you initially access the PDMP?
How often do you subsequently review the PDMP findings?
What type of resources do you try to utilize to address psychosocial determinates?
Unstable housing
Vocational needs
Legal problems
Transportation barriers
Other
If other, please list:
What is your approach to managing patients who present with comorbid pain issues?
What information do you want prospective MAT patients seeking services to know about your practice?
Access
Within how many days can you see new patients?
Please select...
3 days
5 days
7 days
Other
Approximately how many days do new patients wait for an appointment?
Can you accommodate a new patient needing to be seen within 12-24 hours?
Please select...
Yes
No
How can a new patient schedule an appointment?
Please select...
Receptionist
Nurse or Staff by phone assessment
Triage criteria assessed
After-hours contact
Online request
Do you have on-call availability for emergencies?
Please select...
Yes
No
Attestation
By checking here, you are verifying that you are the provider who completed this form or, if completing for another provider, that you have the authority to complete this form on behalf of that provider.
I agree
Name of Person filling out form
Email of person filling out form
Contact Information