Patient Financial Services Survey

1. When did your most recent involvement with Patient Financial Services occur?

	MM		DD		YYYY
MM/DD/YYYY	When did your most recent involvement with Patient Financial Services occur? MM/DD/YYYY Month	/	Day	/	Year

2. Please describe your most recent experience with Patient Financial Services.

Please describe your most recent experience with Patient Financial Services. I received written correspondence from Patient Financial Services (statement or letter)

I received a call from Patient Financial Services

I placed a call to Patient Financial Services

I paid a bill online

I requested online bill pay support

I had a question about a charge on my account

I had a question about my insurance

I had a question about Worker's Compensation

I needed online bill pay support

3. Please tell us about your most recent experience with Patient Financial Services by rating the following:

	Very Good	Good	Fair	Poor	Very Poor	Not Applicable
Ability to reach a representative within a reasonable amount of time	*Please tell us about your most recent experience with Patient Financial Services by rating the following: Ability to reach a representative within a reasonable amount of time Very Good	Ability to reach a representative within a reasonable amount of time Good	Ability to reach a representative within a reasonable amount of time Fair	Ability to reach a representative within a reasonable amount of time Poor	Ability to reach a representative within a reasonable amount of time Very Poor	Ability to reach a representative within a reasonable amount of time Not Applicable
Friendliness and courtesy of the representative	Friendliness and courtesy of the representative Very Good	Friendliness and courtesy of the representative Good	Friendliness and courtesy of the representative Fair	Friendliness and courtesy of the representative Poor	Friendliness and courtesy of the representative Very Poor	Friendliness and courtesy of the representative Not Applicable
Representative's willingness to listen carefully to you	Representative's willingness to listen carefully to you Very Good	Representative's willingness to listen carefully to you Good	Representative's willingness to listen carefully to you Fair	Representative's willingness to listen carefully to you Poor	Representative's willingness to listen carefully to you Very Poor	Representative's willingness to listen carefully to you Not Applicable
Representative's ability to explain things clearly	Representative's ability to explain things clearly Very Good	Representative's ability to explain things clearly Good	Representative's ability to explain things clearly Fair	Representative's ability to explain things clearly Poor	Representative's ability to explain things clearly Very Poor	Representative's ability to explain things clearly Not Applicable
Representative's ability to solve your problem or answer your question	Representative's ability to solve your problem or answer your question Very Good	Representative's ability to solve your problem or answer your question Good	Representative's ability to solve your problem or answer your question Fair	Representative's ability to solve your problem or answer your question Poor	Representative's ability to solve your problem or answer your question Very Poor	Representative's ability to solve your problem or answer your question Not Applicable
Overall quality of statements or letters received from Patient Financial Services	Overall quality of statements or letters received from Patient Financial Services Very Good	Overall quality of statements or letters received from Patient Financial Services Good	Overall quality of statements or letters received from Patient Financial Services Fair	Overall quality of statements or letters received from Patient Financial Services Poor	Overall quality of statements or letters received from Patient Financial Services Very Poor	Overall quality of statements or letters received from Patient Financial Services Not Applicable
Overall ease and convenience of the online bill pay service	Overall ease and convenience of the online bill pay service Very Good	Overall ease and convenience of the online bill pay service Good	Overall ease and convenience of the online bill pay service Fair	Overall ease and convenience of the online bill pay service Poor	Overall ease and convenience of the online bill pay service Very Poor	Overall ease and convenience of the online bill pay service Not Applicable
Overall quality of the billing process	Overall quality of the billing process Very Good	Overall quality of the billing process Good	Overall quality of the billing process Fair	Overall quality of the billing process Poor	Overall quality of the billing process Very Poor	Overall quality of the billing process Not Applicable
Overall satisfaction with Patient Financial Services	Overall satisfaction with Patient Financial Services Very Good	Overall satisfaction with Patient Financial Services Good	Overall satisfaction with Patient Financial Services Fair	Overall satisfaction with Patient Financial Services Poor	Overall satisfaction with Patient Financial Services Very Poor	Overall satisfaction with Patient Financial Services Not Applicable