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Provider Surveys for Medical, Dental, and Mental Health Professionals

The federal Shortage Designation Branch requires specific data to be submitted in applications requesting designation of an area or population group as a Health Professional Shortage Area (HPSA) or Medically Underserved Area/Population (MUA/P). The required information consists largely of primary care providers names, specialties, office locations, hours per week in patient care activities, information on the provider's patient population, and information on other activities the provider might be engaged in outside of patient care. Detailed data requirements are available for your review at the Health Resources and Services Administration shortage designation webpage.

In reviewing the designation status of areas within Michigan, the Department of Community Health collects data primarily through phone surveys of provider offices. In the case of primary medical care physicians, data is also collected through the Michigan Survey of Physicians distributed to physicians with their license renewal information. The documents below are the current versions of the surveys used by the Michigan Department of Community Health to collect shortage designation data. Reviewing these surveys should assist in familiarizing you with the information required for evaluating shortage designations. Interested providers and offices may also feel free to proactively complete surveys and return them to the Department. This effort may be especially valuable to your area if it is scheduled for review. HPSA designations currently scheduled for review may be found by following the instructions found on the webpage titled: "What HPSA Designations are Scheduled for Review?" 

For primary medical care HPSAs and for MUA/P designations, the following survey is used:
Primary Medical Care Physician Survey Form 

For mental health care HPSA designations, the following survey is used:
Mental Health Care Provider Survey Form 

For dental health care HPSA designation, the following survey is used:
Dental Health Care Provider Survey Form 

Please return completed surveys to:

Ryan Grinnell, MPA
Michigan Primary Care Association
rgrinnell@mpca.net
Fax: (517) 381-8008

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