Question Title

* 1. What location are you receiving medical care at?

Question Title

* 2. Our records show that you received care from a provider named below in the last 6 months. Please select the provider name below.

Question Title

* 3. Do you receive Medication Assisted Treatment with InterCommunity for Opioid Use Disorder?

Question Title

* 4. The questions in this survey will refer to the provider named in Question 2 as “this provider.” Please think of that person as you answer the survey.  

Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

Question Title

* 5. How long have you been going to this provider?

Question Title

* 6. These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

In the last 6 months, how many times did you visit this provider to get care for yourself?

Question Title

* 7. In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury, or condition that needed care right away?

Question Title

* 8. In the last 6 months, when you contacted this provider’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?

Question Title

* 9. In the last 6 months, did you make any appointments for a check-up or routine care with this provider?

Question Title

* 10. In the last 6 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?

Question Title

* 11. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours?

Question Title

* 12. In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

Question Title

* 13. In the last 6 months, how often did this provider explain things in a way that was easy to understand?

Question Title

* 14. In the last 6 months, how often did this provider listen carefully to you?

Question Title

* 15. In the last 6 months, how often did this provider seem to know the important information about your medical history?

Question Title

* 16. In the last 6 months, how often did this provider show respect for what you had to say?

Question Title

* 17. In the last 6 months, how often did this provider spend enough time with you?

Question Title

* 18. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?

Question Title

* 19. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

Question Title

* 20. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

Question Title

* 21. In the last 6 months, did you take any prescription medicine?

Question Title

* 22. In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

Question Title

* 23. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

Question Title

* 24. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

Question Title

* 25. In general, how would you rate your overall health?

Question Title

* 26. In general, how would you rate your overall mental or emotional health?

Question Title

* 27. What is your age?

Question Title

* 28. Are you male or female?

Question Title

* 29. What is the highest level of school that you have completed?

Question Title

* 30. Are you of Hispanic or Latino origin or descent?

Question Title

* 31. What is your race. Mark one or more.

Question Title

* 32. Did someone help you complete the survey?

Question Title

* 33. How did that person help you? Mark one or more.

T