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P.O. Box 9010

Morgantown, WV 26506

 

MDTV Pediatric Telemedicine Survey


* Required

*Name:
*E-mail:
Site/Department:

ARE YOU INTERESTED IN TELEMEDICINE? YES NO

If No, please explain why and then hit submit.

If yes, please continue with this survey.

Practice Background Information
What is your specialty?
What county is your practice located in?
What is the approximate number of patients in your practice?
What is the approximate number of patients in your practice under the age of 18?
Type of insurance(s) your office accepts: (Mark all that apply) Medicare
Medicaid
Private Insurance/Blue Cross (included managed care)
Workers Compensation
Other (specify)

Referral Information
How frequently do you refer patients to specialists for consultations? Patients per month
Approximately what percentage of your patients have to travel to a different community to be seen by a specialist? Percentage
What facility(s) do you refer your patients to the most?
What specialty(s) are the most frequently referred to other service providers?

Telemedicine Information
Approximately how many times in the last year have you used telemedicine for any purpost? Patient Encounter
Continuring Education
Administrative Event
How much time (in minutes) on average does it take you to get from your office to the place where the telemedicine equipment is located? Minutes
Please check all types of care you would consider using telemedicine for in your practice: Initial Office Visit
Follow-up Visit
Emergency Care
Preventative Services
Chronic Condition Management
Post Surgical Follow-Up
Acute Non-Emergency Care
Home Health Care

Additional Comments and Information:

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