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Americans with Disabilities Act (ADA) Survey

The purpose of this accessibility survey is to determine whether or not a Provider Office has barriers to access by people with a variety of disabilities. Reviewing Offices for accessibility is one of the most effective ways LIBERTY Dental Plan can ensure that Providers are complying with the Americans with Disabilities Act (ADA).

Please understand that our assessment of your ADA compliance is required by The Centers for Medicare and Medicaid Services (CMS).

There are no wrong answers in any parts of the survey. Please choose the answer which best describes your office environment.

Your completed survey will help us to better serve our members. Thank you.

---PARKING---
---EXTERIOR ROUTE --- (from accessible parking, public transportation, and public sidewalk to the entrance)
---RAMPS---
---BUILDING ENTRANCE---
---INTERIOR ROUTE--- (from the building entrance to the clinic/office entrance, to the registration counter/window, and through the clinic/office to areas that patients could go)
---ELEVATORS--- (If not applicable, skip to the Restroom section)
---RESTROOM---
---EXAM ROOM---
---OTHER---








Please only click Submit once

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