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* 1. Please select the healthcare provider you generally see,

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* 2. In the last 12 months, when you called your healthcare provider’s office to get an appointment for care you needed right away, how often did you get that appointment within the expected timeframe?

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* 3. In the past 12 months, when you called your healthcare provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

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* 4. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see your healthcare provider within 15 minutes of your appointment time?

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* 5. In the last 12 months, how often did your healthcare provider give you easy to understand information about your current healthcare questions and concerns?

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* 6. In the last 12 months, when your healthcare provider ordered a blood test, x-ray or imaging, how often did someone from the office follow-up to give you those results?

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* 7. Using a scale from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you rate your healthcare provider?

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* 8. In the last 12 months, how often did the office staff treat you with courtesy and respect?

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* 9. In the last 12 months, how often did you leave your healthcare provider’s office understanding your current medications as well when and how to take them?

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* 10. In the last 12 months, how often were your prescriptions refilled in a timely manner and to the correct pharmacy?

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* 11. How likely are you to recommend your healthcare provider to a friend or family member?

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* 12. In the past 12 months, when you called your healthcare provider’s office after-hours, how often did you receive a call back within a reasonable timeframe?

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* 13. Please rate your overall experience from 0 to 10, with 0 being the worst experience and 10 being the best experience.

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* 14. Please include any additional comments you may have.

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