OUTPATIENT FACILITY INFORMATION
1. Hours of operation: (indicate hours
clinic is open, i.e., 8-4; 12-6)
| Sun |
Mon |
Tue |
Wed |
Thur |
Fri |
Sat |
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2. A. Medical Director
_______________________________________________
(if applicable)
(name)
B. Director of Nursing
_______________________________________________
(if applicable)
(name)
C. Number of Staff Physicians
(excluding Medical Director) F/T _____ P/T _____
3. Administrative Staff:
Person in charge of Medical
Records ___________________________________
4.
|
Other Employees Staffing
|
F/T
|
P/T
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Other Employees Staffing
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F/T
|
P/T
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| Nurse Practitioners |
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Housekeeping |
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| Physician Assistants |
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Maintenance |
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| R.N.'s |
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X-ray Techs |
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| L.P.N.'s |
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Social Workers |
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| Nurse's Aides |
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Respiratory Therapists |
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| Pharmacists |
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Nutritionists |
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| Laboratory Techs |
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Others |
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5. SERVICES OFFERED:
| Dental |
| Emergency Care |
| E.K.G. |
| Family Planning |
| Home Health Care |
| Immunizations |
| Inhalation Therapy |
| Laboratory |
| Maternity |
| Outpatient Surgery |
| Pharmacy |
| Podiatric Services |
| Social Services |
| Substance Abuse Services |
| T.B. Screening |
| Well-baby Clinic |
| W.I.C. Program |
| X-ray |
| V.D. Detection/Treatment |
| Opth. Testing |
| Other |