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FULL NAME*
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PROVIDER TYPE*
What kind of Healthcare Provider are you?
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Acute care hospitals
Ambulatory surgical centers
Assisted Living Facilities
Behavioral health providers (e.g., substance use disorder, counseling, psychiatric services)
Dental services
Diagnostic services (e.g., independent imaging, radiology, labs)
DME / suppliers (Durable Medical Equipment)
Eye and vision services
Home and community-based support (e.g., housing services, care navigators, case management)
Home health agencies
Inpatient behavioral facilities (e.g., inpatient rehabilitation facilities, long-term acute care hospitals, other residential facilities)
Multi-specialty practices
Nursing homes and skilled nursing facilities
Other ancillary services (e.g., chiropractors, speech and language pathologists, physical therapy, occupational therapy)
Other inpatient facilities
Other outpatient clinics (e.g., urgent care, dialysis center)
Other services (e.g., foster care, developmental disability services)
Other single-specialty practices
Pediatrics practices
Pharmacies
Primary care practices
OTHER
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HOW CAN WE HELP?*
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