Americans with Disabilities ACT (ADA) and Access Provider Survey

MANDATORY SUBMISSION for

MMAI, ICP, FHP, MA HMO and MA PPO

Providers ONLY!


To determine compliance with the ADA ACT and CMS accessibility requirements, Blue Cross and Blue Shield of Illinois (BCBSIL) is requiring that practices complete the following survey for each affiliated office location by Dec. 1, 2015. Detailed information on the ADA Act, can be found at: www.ada.gov.

Please be sure to respond to all questions and information requests. If you need assistance completing this survey, please send an email to govproviders@bcbsil.com.

Thank you for your participation!
Section 1: Demographics

Items marked with an asterisk (*) are mandatory.*
Provider Name*

Provider Practice Name*

Address 1*
Suite
City* State* Zip*
Contact Telephone Number*
(e.g., XXX-XXX-XXXX)
Practitioner License Number:*
Practitioner NPI:*
Section 2: Access/Accessibility

1. Does the office have a 24 hour answering service when the office is closed?*
2. Are answering service call logs maintained for 1 year?*
3. Does the practice have a physician on-call 24 hours a day?*
4. Does the MD respond to emergent phone calls within 30 minutes?*
5. For an Immediate Visit, is a patient seen within 24 hours of request? *
6. For a Routine Visit, is a patient seen within 10 business days or 2 weeks of request?*
7. For an Extended Preventive Care visit, is a patient seen within 4 weeks of request?*
8. If the office treats infants <6 months of age, is a preventive care visit scheduled within 2 weeks of request? *
9. If the office provides OB care, are initial prenatal visits scheduled per the below timelines: *
a. 1st Trimester within 2 weeks of request?*
b. 2nd Trimester within 1 week of request?*
c. 3rd Trimester within 3 days of request?*
10. Are patients notified when the MD wait time exceeds 30 minutes? If yes, please indicate how patients are notified: *
11. Are walkways from public transportation to the office paved and accessible to wheelchairs?*
12. Is Handicap parking available according to ADA Requirements? (Adequate location and number of spaces available with required signage) *
13. Is equipment available (lift, transfer board or low exam table) to transfer patients from a wheelchair to exam table? *
14. Is the office and facility clean and organized?*
15. Are office patient areas, halls and doorways accessible to wheelchairs, motorized scooters and walkers? *
16. Is the waiting room well-lit for reading with adequate seating in the waiting room for patient volume? *
17. Are there an adequate number of private exam rooms for the number of physicians? *
18. Is at least one building entrance wheelchair accessible (ramp and auto door open functions)?*
19. Does the office have at least one exam room that is handicap accessible (doorways and hallways at least 36” wide? *
20. Does the Provider Facility have a handicap accessible scale (wheelchair can be rolled on it)?*
21. Does the office have at least one restroom that is handicap accessible (restroom doorway at least 36” wide to accommodate wheelchairs, motorized scooters and walkers and has grab bars)? *
22. Is there handicap accessible signage by the restrooms (high contrast/ raised lettering and braille)?*
23. If the provider’s office is not on the 1st floor, is the office serviced by a working elevator that is accessible by a wheelchair or motorized scooter? *
24. Are facility and office EXIT signs high contrast (red on green, red on white)?*
Items marked with an asterisk (*) are mandatory.