The Compliance Team

Patient Satisfaction Survey — Rural Health Clinic

Items below designated with an asterisk ( *) are required.
Requested By:	John Bellamy at
Your Name:	First: Last:
Your Phone #:	Use the following format (XXX) XXX-XXXX
New or Existing Patient:*	New Existing
:*
Make or Serial # (as applicable):
Date of Service:*	(mm/dd/yyyy format)
Provider Name:* Unknown

	Access, Delivery and Service	Yes	No	N/A
1	I received an appointment in a timely fashion.
2	The person who answered the phone and made the appointment was courteous and helpful.
3	The wait time to be seen by a provider was timely.
4	The services I received were appropriate and addressed my needs.
5	My appointment needs were handled in a confidential and professional manner.
6	My medical questions were answered and addressed in a way that I understood.
7	I have been informed and understand my diagnosis.
8	I have been informed of and understand the treatment plan.
9	All of the staff that I interacted with treated me respectfully and professionally.
10	I was 100% satisfied with my overall experience and the health services provided.

COMMENTS:

We greatly appreciate your input. We use patient satisfaction survey reports to help us improve our day-to-day services. Please take an extra minute to provide details for your survey responses in the box below.