Patient Financial Services Survey

Patient Financial Services: How well did we serve you?

We want to ensure that you receive the best customer service. Please let us know how we are doing and how we can improve to provide you with a great experience.

Name:

Date Patient Financial Services assisted you?

Name of Customer Service Specialist who assisted you:

Name of Customer Service Specialist who assisted you: Barbara

Jennifer

Maricela

Patty

Sylvia

Please use this scale to answer the following questions: 4, Excellent (exceeded my expectations; 3, Good (met my expectations); 2, Fair; 1, Poor; NA, Not applicable (unable to evaluate)

	4(Excellent)	3(Good)	2(Fair)	1(Poor)	N/A
1. The staff communicated effectively.	*Please use this scale to answer the following questions: 4, Excellent (exceeded my expectations; 3, Good (met my expectations); 2, Fair; 1, Poor; NA, Not applicable (unable to evaluate) 1. The staff communicated effectively. 4(Excellent)	1. The staff communicated effectively. 3(Good)	1. The staff communicated effectively. 2(Fair)	1. The staff communicated effectively. 1(Poor)	1. The staff communicated effectively. N/A
2. My request was met within the time frame given.	2. My request was met within the time frame given. 4(Excellent)	2. My request was met within the time frame given. 3(Good)	2. My request was met within the time frame given. 2(Fair)	2. My request was met within the time frame given. 1(Poor)	2. My request was met within the time frame given. N/A
3. Personnel was easy to reach in the Business Office.	3. Personnel was easy to reach in the Business Office. 4(Excellent)	3. Personnel was easy to reach in the Business Office. 3(Good)	3. Personnel was easy to reach in the Business Office. 2(Fair)	3. Personnel was easy to reach in the Business Office. 1(Poor)	3. Personnel was easy to reach in the Business Office. N/A
4. Financial responsibility information was clearly explained to me.	4. Financial responsibility information was clearly explained to me. 4(Excellent)	4. Financial responsibility information was clearly explained to me. 3(Good)	4. Financial responsibility information was clearly explained to me. 2(Fair)	4. Financial responsibility information was clearly explained to me. 1(Poor)	4. Financial responsibility information was clearly explained to me. N/A
5. The explanation of the bill for services was appropriate.	5. The explanation of the bill for services was appropriate. 4(Excellent)	5. The explanation of the bill for services was appropriate. 3(Good)	5. The explanation of the bill for services was appropriate. 2(Fair)	5. The explanation of the bill for services was appropriate. 1(Poor)	5. The explanation of the bill for services was appropriate. N/A
6. Follow through of questions and answers was met.	6. Follow through of questions and answers was met. 4(Excellent)	6. Follow through of questions and answers was met. 3(Good)	6. Follow through of questions and answers was met. 2(Fair)	6. Follow through of questions and answers was met. 1(Poor)	6. Follow through of questions and answers was met. N/A
7. The staff was courteous and respectful.	7. The staff was courteous and respectful. 4(Excellent)	7. The staff was courteous and respectful. 3(Good)	7. The staff was courteous and respectful. 2(Fair)	7. The staff was courteous and respectful. 1(Poor)	7. The staff was courteous and respectful. N/A
8. Overall customer service score.	8. Overall customer service score. 4(Excellent)	8. Overall customer service score. 3(Good)	8. Overall customer service score. 2(Fair)	8. Overall customer service score. 1(Poor)	8. Overall customer service score. N/A
9. I felt all payment options were explained to me.	9. I felt all payment options were explained to me. 4(Excellent)	9. I felt all payment options were explained to me. 3(Good)	9. I felt all payment options were explained to me. 2(Fair)	9. I felt all payment options were explained to me. 1(Poor)	9. I felt all payment options were explained to me. N/A

Comments?

Is there anything you would like to share with your Customer Service Specialist about your service today?

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Patient Financial Services: How well did we serve you?

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