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Medicare-Medicaid Provider Directory Required Data Survey CMS has (Absolute Total Care)

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1441 Main Street
Suite 900
Columbia, SC 29201
1
-
855
-
735
-
4398
TTY: 711
absolutetotalcare.com
Medicare-Medicaid Provider Directory Required Data Survey
CMS has provided guidance on data elements which will be required for tracking purposes and
will be published in our Provider Directory as well as our online Find A Provider tool (FAP). These
data elements need to be collected and will be required to be updated regularly. This brief
questionnaire has been designed to easily collect this information by location.
Please answer the questionnaire to the best of your ability and knowledge. Please ensure you
answer every question and nothing is left blank. The information you report will be presented in
the Provider Directory and on FAP.
Provider Identification Numbers
Tax ID:
NPI:
Legal Entity Name:
Location Address:
City: , State: Zip code:
Practice Location Phone:
Practice Location Contact Person:
Practice Email:
Practice Location Hours of Operation:
Would you like this location displayed in our online directory? Yes or No:
Monday AM to PM
Tuesday AM to PM
Wednesday AM to PM
Thursday AM to PM
Friday AM to PM
Saturday AM to PM
Sunday AM to PM
1-855-735-4398
TTY: 711
http://mmp.absolutetotalcare.com
Is the provider's location on an accessible public transportation route?
Does this location offer non-English languages (including ASL) on-site by qualified Healthcare
interpreters? Yes or No:
If above is yes, which non-English languages are provided on-site at this location?
For this practice location, please specify which accessibility
options you have for individuals with physical disabilities:
YES NO
ADA Parking spaces, curb ramps, or loading zones at building
entrance
Doorways wide enough to ensure safe passage by individuals using
mobility aids Wheelchair accessible restrooms with grab bars and
accessible lavatories
ASL Signage and raised tactile text characters at office, elevator, and
restroom doors
ADA Exam Table/Scale
Medical equipment accessible to patients using mobility aids
Exam rooms accessible to patients using mobility aids
Type YES NO
Bus
Train
YES NO
American Sign Language (ASL)
Arabic
Cantonese
French
German
Haitian
Hindi
Italian
Japanese
Korean
Mandarin
1-855-735-4398
TTY: 711
http://mmp.absolutetotalcare.com
Does this location offer translation services for written materials? Yes or No:
Do any providers listed above have specialized training in treating the following?
Specialized Training Area
YES NO Provider Last Name
Physical disabilities
Intellectual and developmental
disabilities
Chronic illness
HIV/AIDS
Serious mental illness
Substance abuse
Homelessness
Deafness or hard-of-hearing
Blindness or visual impairment
Co-occurring disorders
Other (Please specify)
Polish
Portuguese
Russian
Spanish
Tagalog
Vietnamese
Other (Please specify)
Please provide the following information for each Physician that works at this location:
Provider First Name
Provider Last Name Individual NPI
1-855-735-4398
TTY: 711
http://mmp.absolutetotalcare.com
Do any providers listed above have specialized training in treating the following?
Cultural Competency Training
YES NO Provider Last Name
African American
Alaskan Native
American Indian
Asian
Hispanic/Latino
Pacific Islander
Other (Please specify)
Please send completed survey to:
Absolute Total Care
Attention: Provider Relations
1441 Main Street
Suite 900
Columbia, SC 29201
Fax: 1-866-912-3605
atcprime@centene.com
You may also contact your Provider Network Specialist to have the document picked up from
your office.
Our partnership is vital in providing our members with quality healthcare. If you have any
questions please do not hesitate to call us at 1-866-433-6041, Monday through Friday from 8
a.m. to 6 p.m.
Sincerely,
Absolute Total Care
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Medicare-Medicaid Provider Directory Required Data Survey CMS has (Absolute Total Care)

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Completed 5 May 2021

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