MyChart and Your Health Question Title * 1. Do you currently have a MyChart account with Samaritan Health Services? Yes No OK Question Title * 2. If you have a MyChart account, have you used it to communicate with Samaritan ? Yes No OK Question Title * 3. If so, which features have you used? Please check all that apply. Refill a prescription E-visit Send a message to your health care team View notes from a recent visit View your test results Schedule an office visit View your health summary View your billing summary Share your health care record OK Question Title * 4. How would you rate your experiences with MyChart? Excellent Very Good Good Fair Poor I have not used MyChart OK Question Title * 5. What features would you find helpful in MyChart that Samaritan doesn’t currently offer? OK Question Title * 6. We appreciate the opportunity to share the stories of our patients who have had great experiences with Samaritan. If you have had a good experience with Samaritan using MyChart, would you be willing to share your story and contact information with us? Yes No If yes, please provide your name, email address and/or phone number here. OK Question Title * 7. If you don't have a MyChart account, would you be willing to tell us why? I'm not comfortable with technology I'm not interested in accessing my health information I don't have a way to access MyChart - no computer or mobile device I've never heard of MyChart/I've never been offered a MyChart account before I'd prefer not to say Other (please specify) OK Question Title * 8. If you haven't heard of MyChart before, would any of these features make you interested in signing up? Please check all that apply.(And if you'd like to sign up today, visit samhealth.org/MyChart!) Refill a prescription Schedule an office visit E-visit for non-urgent condition Send a message to your health care team View notes from a recent visit View your health record View test results View your billing Share your health care record OK Question Title * 9. If you currently don’t have a MyChart account, what features would you find helpful besides the features listed in the previous question? OK DONE