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Exemplary Provider Satisfaction Measure
©
— Universal Survey
Requested By:
Edward Arabov at Healthy Corner Pharmcy
Your Name:
First:
Last:
Your Phone #:
New or Existing Patient:
New
Existing
Equipment Category:
Accapella Device
Air Compressor
Ankle Gauntlet
Automatic External Defibrillators (AEDs)
Bath-Transition Items
Blood Glucose Monitors and Supplies (mail order)
Blood Glucose Monitors and Supplies (non-mail order)
Blood Pressure Monitor
Breast Prostheses and Accessories *
Breast Pumps & Accessories
Canes and Crutches
Cochlear Implants *
Commodes/Urinals/Bedpans
Compression Garments-Juzo/Jobst
Continuous Passive Motion (CPM) Devices
Continuous Positive Airway Pressure (CPAP/BIPAP) Devices-Non Clinical
Contracture Treatment Devices: Dynamic Splint
Cranial Prosthetic
Dental Oral Appliance
Diabetic Shoes/Inserts-custom *
Diabetic Shoes/Inserts-Off-the-Shelf
Enteral Nutrients, Equipment and Supplies
Epoetin
External Infusion Pumps and Supplies
Eye Prostheses *
Facial Prostheses *
Gastric Suction Pumps
Heat & Cold Applications
Hemodialysis Equipment and Supplies
High Frequency Chest Wall Oscillation (HFCWO) Devices
Home Dialysis Equipment and Supplies
Home INR Monitoring
Hospital Beds Semi-Electric
Hospital Beds-Electric
Hospital Beds-Manual
Immunosuppressive Drugs
Implanted Infusion Pumps and Supplies
Incontinence
Inflatible Donut
Infrared Heating Pad Systems
Infusion Drugs
Insulin Infusion Pumps and Supplies
Interferential Muscle Stimulator
Intermittent Positive Pressure Breathing (IPPB) Devices *
Intrapulmonary Percussive Ventilation Devices *
Invasive Mechanical Ventilation Devices *
Limb Prostheses *
Mechanical In-Exsufflation Devices
Medical Alarms & Monitoring
Nebulizer Drugs
Nebulizer Equipment and Supplies
Negative Pressure Wound Therapy Pumps and Supplies
Neuromuscular Electrical Stimulators (NMES)
Neurostimulators
No Product Category-Corporate
No Product Category-Warehouse
Ocular Prostheses *
Oral Anticancer Drugs
Oral Antiemetic Drugs
Orthoses: Custom Fabricated *
Orthoses: Off-The-Shelf
Orthoses: Prefabricated (non-custom fabricated) *
Osteogenesis Stimulators
Ostomy Supplies
Oxygen Equipment and Supplies
Parenteral Nutrients, Equipment and Supplies
Patient Lifts
Penile Pumps
Pneumatic Compression Devices
Power Operated Vehicles (Scooters)
Prosthetic Lenses: Conventional Contact Lenses *
Prosthetic Lenses: Conventional Eyeglasses *
Prosthetic Lenses: Prosthetic Cataract Lenses *
Pulse Oximeter Device
RADS
Respiratory Assist Devices (BIPAP Clinical) *
Respiratory Suction Pumps
Resuscitation bag-Ambu Bag
Rubber Gloves
Seat Lift Mechanisms
Shingles-Vaccine
Shower chair
Somatic Prostheses *
Spacer-Childrens Inhaler
Speech Generating Devices
Stair-Lifts
Support Surfaces: Pressure Reducing Beds/Mattresses/Overlays/Pads
Surgical Dressings
Tracheostomy Care Supplies
Tracheostomy Supplies
Traction Equipment
Transcutaneous Electrical Nerve Stimulators (TENS) and Supplies
Transport Chair
Ultraviolet Light Devices
Urological Supplies
Vacuum Erection Devices
Vehicle Lift Install/Repiar
Ventilators Accessories/Supplies
Voice Prosthetics *
Walkers/Rolators
Wearable Cardioverter Defibrillator(WCD)
Wheelchair Seating/Cushions
Wheelchairs-Complex Rehabilitative Manual *
Wheelchairs-Complex Rehabilitative Manual Wheelchairs Related Accessories *
Wheelchairs-Complex Rehabilitative Power *
Wheelchairs-Complex Rehabilitative Power Wheelchairs Related Accessories *
Wheelchairs-Standard Manual
Wheelchairs-Standard Manual Related Accessories
Wheelchairs-Standard Power
Wheelchairs-Standard Power Related Accessories
Wound Care
Model or Serial # (as applicable):
Date Of Service:
(mm/dd/yyyy format)
Delivery and Instruction Tech Name:
Access, Delivery and Service
Yes
No
N/A
1
Equipment/supplies were delivered in a timely manner.
2
Equipment/supplies were ready for patient use upon delivery.
3
Received and understood instructions on proper application and use of equipment/supplies.
4
Feel confident to operate/use equipment/supplies.
5
Received info on my Rights & Responsibilities, complaint process, billing, contact numbers.
6
Response to my questions, problems, concerns were addressed in a timely manner.
7
Satisfied with the equipment or supplies.
8
Satisfied with the service. Would recommend to others.
Comments
©2023 The Compliance Team, Inc. P.O. Box 160, 905 Sheble Lane, Suite 102, Spring House, PA 19477