Coronavirus Community Care Network Provider Interest Form

The City of Detroit is coordinating primary care providers for uninsured residents to receive COVID-19 evaluations and (if required) prescriptions. If you are interested in serving as a provider for this operation, please complete the fields below.

Name*

Organization*

Title

Phone*

E-mail

Accepting New Patients*

Are you currently accepting new patients? We are seeking healthcare providers who are willing to take new patients to serve residents without providers or insurance.

Yes

Patients Without Insurance*

Are you willing to accept patients who do not have insurance so that they can receive an evaluation to determine if they need a prescription for COVID19 testing at the CCCN drive thru testing site? If you are not willing to accept patients without insurance, we will note that on our website in the list of providers.

Clinic Name

What is the name of the clinic?

Clinic Address

Appointment Line for Patients

What is the direct phone number patients should call to schedule an appointment?

Do you provide Tele Health or Tele Medicine*

Telehealth

Telemedicine

Both

Nothing

Do you provide financial assistance for patients?*

Sliding Fee Scale

Waive Fee on first appointment

Nothing

Other

Insurance Types

What are the insurance types you accept?

Medicaid and Medicare*

Do you accept Medicaid and Medicare? Check the box if yes.

Medicaid

Medicare

Both

Neither

Comments or Questions

Next Steps

Thank you so much for your support and partnership in this effort. We will be posting your information on our provider network referral website. Please also review the MDHHS guidance for COVID19 testing. Patient lab results will be shared with you via the Michigan Health Information Network. The City of Detroit will also be setting up a transportation service for those patients who do not have access to transportation to the drive-thru testing site.

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