Patient Issue Resolution Form

Patient Issue Resolution Form

At Diabetes Management & Supplies, we strive to solve any patient issues within 24 hours. Please complete the below information so we may assist you as quickly as possible.

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* 1. For faster resolution of your concern, please fill out the information below.

Name of Representative you are working with(If Known)

Your Name

Patient Number(If Known)

Telephone/Cellular Phone Number

E-mail Address

Question Title

* 2. Please explain the nature of your concern or issue.

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* 3. What is your desired outcome of the concern or issue?

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* 4. Please add any additional comments or concerns regarding this situation.

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* 5. We will investigate this situation and you will receive a response back within 24 hours.

Date / Time

Date

Time

AM/PM