The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

pJETCy3aAyghogzNb5cN2L9e7c9K6maQugErTAfJVj2cGE6LiNfYS9AP8b2rPwueCtFJPzYCx3N7NecNabjwVnEhUogBWSscvBjRIubutLMbE

DACS Sign-Up Form

DACS is a grant-funded program sponsored by DC Health. Therefore, the names of participating providers as well as information collected by DACS may be shared with district officials as requested. DACS provides de-identified, “curbside” consultations for providers about their patients and does not assume liability for any direct patient care. Prescribers who sign up for DACS will be informed about upcoming training opportunities.

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Sign-Up Date

* must provide value

M-D-Y

Prescriber First Name

* must provide value

Prescriber Last Name

* must provide value

Practitioner Type

* must provide value

Please specify if "Other":

* must provide value

Primary Practice Name (if applicable):

Phone Number

* must provide value

Would you like to receive Text messages from DACS at this phone number?

* must provide value

Yes

Alternative Phone Number (if applicable)

Fax Number

Prescriber Email

Best way to contact prescriber

* must provide value

Phone

Fax

Other

Please specify if "other":

Gender

* must provide value

Please self-describe:

* must provide value

Do you consider yourself Hispanic or Latinx?

* must provide value

What do you consider to be your racial identity? (Select all that apply)

* must provide value

Alaska Native American

American Indian

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Prefer to self-describe

Please self-describe:

* must provide value

Primary Practice Address: Street Name

Primary Practice Address: City

Primary Practice Address: State

Primary Practice Address: Zip Code

Primary Practice Address: [Ward or County]

* must provide value

Ward 1

Ward 2

Ward 3

Ward 4

Ward 5

Ward 6

Ward 7

Ward 8

District Wide

Maryland

Allegany County, MD

Anne Arundel County, MD

Baltimore City, MD

Baltimore County, MD

Calvert County, MD

Caroline County, MD

Carroll County, MD

Cecil County, MD

Charles County, MD

Dorchester County, MD

Frederick County, MD

Garrett County, MD

Harford County, MD

Howard County, MD

Kent County, MD

Montgomery County, MD

Prince George's County, MD

Queen Anne's County, MD

St. Mary's County, MD

Somerset County, MD

Talbot County, MD

Washington County, MD

Wicomico County, MD

Worcester County, MD

Virginia

Other

Please specify "Other":

Type of Practice

* must provide value

Solo or Private Practice

Academic Medical Center

Federally Qualified Health Center (FQHC)

Addiction Treatment Program

Public Health Department

Community Mental Health Center

Pain managment

Emergency Department

Other

Please specify if "Other":

* must provide value

Prescriber Type of Specialty

* must provide value

Family Medicine

Internal Medicine

Addiction Medicine

Emergency Medicine

Psychiatry

Pediatrics

Obstetrics/Gynecology

Pain Medicine

Other

Please specify if "Other":

* must provide value

Do you have your buprenorphine waiver?
[OLD - do not use after 2/28/23]

If yes, how many patients are you waivered to see?
[OLD - do not use after 2/28/23]

Please specify if "Other"
[OLD - do not use after 2/28/23]

Do you prescribe buprenorphine?

* must provide value

If planning to prescribe buprenorphine, approximately
when do you expect to begin prescribing? (Month/Year)

If yes, how many patients are you currently seeing?

Are you accepting new patients?

Yes

reset

Have you ever had formal training in addiction medicine?

Yes

reset

Please specify if "yes":

Years in practice:

* must provide value

When applicable, do you normally initiate treatment with non-opioid pain medications and non-pharmacologic pain treatment modalities prior to prescribing opioids to your patients?

* must provide value

Yes

reset

What, if any, guidelines do you follow when prescribing opioids?

* must provide value

How did you hear about DACS?

Presentation at my practice

Drop-in visit to my practice

MACS/DACS training or presentation

Web Search

College/Professional Network

Conference/Professional meeting

Mailing

Newsletter

Social Media

Other

Please specify if "Other":

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