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NHCAC Questionnaire

Organization Information

Your Name:

Service Information

Please confirm that no patient will be denied a service due to their inability to pay

Provider Information

Diabetes Program Information

Please select the educational categories your organization provides to patients diagnosed with diabetes
Are your diabetes patients asked to bring a food log to follow-up appointments?
Do you refer your patients with diabetes to take the Diabetes Self Management Education and Support Programs (DSMES)?

Prediabetes Program Information

Are your prediabetes patients asked to bring a food log to follow-up appointments?
Do you refer your prediabetes patients to the Diabetes Prevention Program?

Lab Information

Partnership Questions

Can you provide our patients with priority appointments based on our partnership?
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