Availability & Virtual Care Questionnaire
Provider Information
Individual Name
Individual NPI
Are you accepting new members?
Please select...
Yes
No
Availability
Please click on one of the following choices to confirm your appointment availability timeframe to treat a Lucet member:
Office Based:
Please select...
within 24 hours
within 2-3 days
within 7 days
greater than 7 days
None
Virtually:
Please select...
within 24 hours
within 2-3 days
within 7 days
greater than 7 days
No availability
Does not provide virtual
Are you interested in starting to provide virtual care?
Please select...
Yes
No
Virtual Care
Are you currently providing Virtual Care using a HIPAA compliant technology method?
Please select...
Yes
No
Are you interested in expanding your virtual care?
Please select...
Yes
No
Are you planning on continuing to provide virtual care post pandemic?
Please select...
Yes
No
Have you found any of the following efficiencies with providing virtual care? (Check all that apply)
Please select...
Reduced no show rates
Ability to see more members
Reduced administrative burden or cost
Other (please explain)
Hold the shift key down when trying to select multiple options
Other
Attestation
By checking here, you are verifying that you are the provider who completed this form or, if completing for a provider, that you have the authority to complete this form on behalf of that provider.
I agree
Name
Position/Title
Email
Date
Contact Information