OTHER PROVIDER FACILITIES IN COMMUNUNITY (Add lines as needed; if not available or not applicable, record N/A.) Type of Provider Name of Facility # Physicians / # Annual # Patients Specify if Visits per Day per FQHC, RHC, # PAs / NPs Provider CMC, CMHC Primary care Multi-specialty Behavioral health Psychiatrist Dental Chiropractic Podiatrist Optometrist Commercial lab Imaging center Retail pharmacy Respiratory therapy Physical therapy Occupational therapy Music therapy Dietician Behavioral health Durable medical equipment Local public health provider Other (specify) Other (specify) Comments:
OTHER PROVIDER FACILITIES IN COMMUNUNITY (Add lines as needed; if not available or not applicable, record N/A.) Type of Provider Name of Facility # Physicians / # PAs / NPs # Annual Visits # Patients per Day per Provider Specify if FQHC, RHC, CMC, CMHC Primary care Multi-specialty Behavioral health Psychiatrist Dental Chiropractic Podiatrist Optometrist Commercial lab Imaging center Retail pharmacy Respiratory therapy Physical therapy Occupational therapy Music therapy Dietician Behavioral health Durable medical equipment Local public health provider Other (specify) Other (specify) Comments:
1-Community-Data-Collection-Form.docx