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Patient Engagement Survey

Your feedback is important to us. Please complete survey below to provide honest feedback about your experience with ABC Health Care and our staff.

Survey Questions *

Please only select one answer per question.

1. I was satisfied with ABC Health Care’s response to any questions, problems, concerns, and/or comments I brought to their attention.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

2. I was satisfied ABC Health Care’s delivery of my items or services (scheduled time vs. actual delivery time).

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

3. I was satisfied with ABC Health Care’s ability to correctly bill my insurance provider(s).

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

4. I was satisfied with ABC Health Care’s ability to provide care, treatment, or service in a safe manner.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

5. I was satisfied with ABC Health Care’s ability to protect the privacy and security of my personal health information?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

6. I was satisfied ABC Health Care’s ability to assess and identify my needs?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

7. I was satisfied with ABC Health Care’s willingness to include me, my family members, and/or my caregivers in the decisions about my care, treatments, and/or services?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

8. I was satisfied with the information and educational materials ABC Health Care provided me regarding the care, treatment, and/or services provided?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

9. I was satisfied with ABC Health Care’s entry in my residence as it pertains to respecting my property?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

10. Overall, I was satisfied with the products and/or services provided to me by ABC Health Care?

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Additional Comments?

Would you like to be contacted by ABC Health Care about your experience with us? *

Yes

No

Patient Name

Provide patient's name if you would like to be contacted by ABC Health Care.

First Name

Last Name

Contact Phone Number

Provide a contact phone number if you would to be contacted by ABC Health Care.

(###)

###

####

Email Address

Provide contact email if you would like to contacted by ABC Health Care.

Thank you for submitting feedback on your experiences with ABC Health Care and our staff. We are always trying to improve and your comments help guide our efforts.

We appreciate your time and willingness to share. Have a great day!

Phone (866) 363-3678 Fax (757) 826-9269

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