Maimonides PFAC Application Thank you so much for your interest in participating in our PFAC. If you have any questions or would like this form in Spanish, Russian, or Chinese, please contact the Office of Patient Experience at 718-283-1200. Question Title * Today's Date Date / Time Date Question Title * Full Name Question Title * Your Email Question Title * Preferred Contact Number Question Title * Your address Question Title * Where did you or your family member receive health services within the passed year at Maimonides Outpatient Surgery/Special Procedures 1025 - 48 street Center of Bones and Joints - CALKO Breast Cancer 745 - 64th Street 6300 - 8th Avenue Cancer Center Emergency Room- Adult Inpatient Adult Emergency Room- Pediatrics Children's Hospital Maternity MDP Maimonides Doctors Pavilion-Outpatient 4813 - 9th Avenue Psychiatry - Mental and Behavioral Health Radiology Other (please specify) Question Title * Are you a Maimo Care user? Yes No Question Title * Please indicate your preference meeting format In-Person Virtual Only (i.e. WebEx, Zoom) No Preferences Done
