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pdfOMB NO.: 0720-0031
EXPIRATION DATE: 08/31/2025
Office of the Assistant Secretary of Defense (HA)
DHA Analytics and Evaluation Division
C/O DataStat, Inc.
3975 Research Park Drive
Ann Arbor, MI 48108
OFFICIAL GOVERNMENT BUSINESS
************AUTO**SCH 5-DIGIT 53562
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DAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTDAFTD
02/05/2025
DSW *001-00001*
Dear Office Manager,
There are three easy ways to complete this 5-minute survey:
https:www.health.mil/Patient-Surveys
Select Survey #3: TRICARE Select Survey for Civilian Providers
Password:
2 Return by Mail
Use the enclosed pre-paid envelope
3 Return by Fax
1-734-663-9084
If you are not the appropriate person to answer these questions, please pass this on to the person in your
office most familiar with billing and insurance. If you have questions about the survey, call 1-866-387-9018.
Thank you in advance for your cooperation.
Sincerely yours,
Melissa D. Gliner, Ph. D.
Analytics and Evaluation Division, Defense Health Agency
Office of the Assistant Secretary of Defense (Health Affairs)
SURVEY QUESTIONS ON REVERSE SIDE
The public reporting burden for this collection of information is estimated to average five (5) minutes to complete, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate,
Information Management Division, [email protected] (0720-0031). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This Official DoD survey
may be confirmed at the TRICARE website https://health.mil/surveys, click on Current Active Surveys, and find "Survey of Civilian Provider Acceptance of TRICARE Select."
PRIVACY ADVISORY STATEMENT
Information is being collected for this Survey under the authority of the FY2015 National Defense Authorization Act (NDAA), Section 712 and will be used to help TRICARE health policy
makers gauge civilian provider awareness and acceptance of the TRICARE Select health care benefit option and provide aggregated input to improve the Military Health System. All
information will be de-identified prior to being reported. Completing the Survey is voluntary; you may stop the Survey at any time and skip any questions you choose. There is no penalty if
you choose not to respond, although maximum participation is encouraged so the data will be complete and representative. Personally identifying information (PII) includes names,
addresses, phone numbers, email addresses, Social Security numbers, medical IDs, etc. and should not be included in survey responses.
DSW-PC
*001-00001*
1 Complete Online
DSW-00469-02
Congress
Congress has
has directed
directed the
the Department
Department of
of Defense
Defense to
to survey
survey civilian
civilian physicians
physicians to
to determine
determine ifif military
military service
service
members
members and
and their
their families
families have
have access
access to
to care
care outside
outside of
of the
the military.
military. To
To assess
assess this,
this, we
we are
are gathering
gathering details
details
surrounding
health
insurance
and
new
patient
acceptance
by
Dr.
.
Even
if
the
provider
surrounding health insurance and new patient acceptance by [Insert Provider Name], [Credentials].
named
longer at
this office,
please at
reply
the first
question
so thatinwe
may
report
Even if is
thenoprovider
named
is no longer
thisto
office,
please
reply in
tothis
the survey
first question
this
survey
soaccurate
that we
statistics
to accurate
Congress.
may report
statistics to Congress.
OMB NO.: 0720-0031
EXPIRATION DATE: 08/31/2025
1.
1.
On average,
average,does
does
Dr.
provide
treatment
On
provide
treatmentto
to
patientsatatleast
least
hours
week?
patients
2020
hours
perper
week?
7.
7.
Yes ➔ Go to Question 2
No, does not provide treatment, has retired, or
2.
2.
As
oftoday,
today,isis
Dr.
a TRICARE
Select
network
As of
a TRICARE
Select
member?
network member?
No
Yes
Don't Know
provides treatment to patients less than 20 hours
per week on average. ➔ Thank you, please
return the questionnaire
Don't know, no longer here. ➔ Thank you, please
return the questionnaire
Whichofofthe
thefollowing
following
best
describes
Dr. 's
Which
best
describes
's
principal employer?
8.
8.
As
oftoday,
today,isis
Dr.
accepting
new new
TRICARE
As of
accepting
Select
patients?
TRICARE
Select patients?
Yes ➔ Go to Question 10
No ➔ Go to Question 9
Don't Know ➔ Go to Question 10
principal employer?
9.
9.
Government-sponsored facility or Government- run
Why
is
Dr.
not accepting
new new
TRICARE
Why is
not accepting
TRICARE
Select
patients?
Select patients?
program
Military or Veteran treatment facility
School, university, or other academic institution
Contractor providing services for employment,
MARK ALL THAT APPLY
Reimbursement too low
Customer service/paperwork problems
Problems with TRICARE in the past
Not aware of TRICARE Select
Inconvenience
Specialty or credential not covered
Prefers TRICARE Prime or TRICARE Plus
Too busy
Only takes private insurance
Problems getting into program/application in
progress
Not accepting new patients
Other
__________________________ (do not include PII)
insurance, or legal proceedings
Closed Panel HMO
Open Panel HMO
Prison or jail
Other _____________________ (do not include PII)
Is
Dr.
a case
manager
and/or
medical
Is
a case
manager
and/or
medical
student?
student?
3.
3.
MARK ALL THAT APPLY
Yes, case manager ➔ Thank you, please return
the questionnaire
Yes, medical student ➔ Thank you, please return
the questionnaire
No, neither a case manager nor medical
student ➔ Go to Question 4
4.
10.
10.
Are
ofof
TRICARE
Select
(formerly
known
as
Are you
youaware
aware
TRICARE
Select
(formerly
known
as
TRICARE
or or
Extra)?
TRICAREStandard
Standard
Extra)?
Yes ➔ Thank you, please return the questionnaire
No ➔ Go to Question 11
Don't Know ➔ Go to Question 12
Yes
No
5.
5.
As of
of today,
today,isis
Dr.
accepting
new new
Medicare
As
accepting
patients?patients?
Medicare
11.
11.
As of
oftoday,
today,does
does
accept
accept
any
of the
As
Dr.Dr.
any
of the
following
following
forms
of health insurance?
forms
of health
insurance?
Whyisis
Dr.
not accepting
new new
Medicare
Why
not accepting
Medicare
patients?
patients?
MARK ALL THAT APPLY
Yes
No
Medicare
Medicaid
TRICARE Select
Private insurance
Other:
Reimbursement too low
Customer service/paperwork problems
Problems with Medicare in the past
Inconvenience
Specialty or credential not covered
Too busy
Only takes private insurance
Problems getting into program/application in
progress
Not accepting new patients
Other
__________________________ (do not include PII)
➔ Go to Question 9
(do not include PII)
Does not accept any insurance
Not applicable, provides treatment free of
charge ➔ Thank you, please return
the questionnaire
6.
6.
As
accept
TRICARE
As of
oftoday,
today,does
does
Dr.
accept
TRICARE
Select as
Select
as payment
payment
in full? in full?
Yes ➔ Go to Question 7
No ➔ Go to Question 8
Don't Know ➔ Go to Question 7
As of today, is Dr. accepting new patients?
12.
As of today, is accepting new
patients?
Yes
No
Don't Know
Thank you for taking the time to complete this survey. Please
put this in the enclosed postage-paid envelope and return it to
the Survey Processing Center or fax the survey to DataStat at
1-734-663-9084. If you have any questions about TRICARE, its
specific health plans, or the benefits it provides, please visit the
TRICARE web site at www.tricare.mil for assistance.
*001-00001*
DSW-00469-02
529-01
12.
01
DSWPC
| File Type | application/pdf |
| File Modified | 2025-01-09 |
| File Created | 2025-01-09 |