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The Compliance Team
Exemplary Provider Satisfaction Measure© — Rural Health Clinic Survey
Requested By: John Bellamy at Crowley Child & Adolescent Clinic
Your Name:
First:      Last:
Your Phone #:
New or Existing Patient:   
Date Of Service:  (mm/dd/yyyy format)
Provider Name:

 Access, Delivery and ServiceYesNoN/A
1I received an appointment in a timely fashion.
2The person who answered the phone and made the appointment was courteous and helpful.
3The wait time to be seen by a provider was timely.
4The services I received were appropriate and addressed my needs.
5My appointment needs were handled in a confidential and professional manner.
6My medical questions were answered and addressed in a way that I understood.
7I have been informed and understand my diagnosis.
8I have been informed of and understand the treatment plan.
9All of the staff that I interacted with treated me respectfully and professionally.
10I was 100% satisfied with my overall experience and the health services provided.

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