Your Information

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* 1. Please select your primary Health Insurance provider:

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* 2. Please select your age range:

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* 3. How long have you been going to your current healthcare provider?

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* 4. In the last 12 months, how many visits have you had with your healthcare provider? 

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* 5. On average, how long do you typically wait to see your healthcare provider (wait time includes time spent in the waiting room and exam room)?

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* 6. What number would you use to rate your healthcare provider?
(Zero (0) being the worst provider possible and ten (10) being the best provider possible)

0 5 10
i We adjusted the number you entered based on the slider’s scale.

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* 7. In the last 12 months, did you contact your provider’s office to get an appointment for an illness, injury or condition that needed care right away?

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* 8. If yes, when you contacted your provider’s office to get an appointment for care you needed right away, how quickly were you offered to get in to see any provider within the practice?

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* 9. Do you have any of the following chronic conditions? Select all that apply.

Disclaimer: We are gauging the interest level for additional Care Coordination services. If you are interested in receiving more information, please discuss this with your PCP.

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* 10. If you have any of the above conditions, would you find it helpful if your healthcare provider's staff called you regularly to check in on you regarding your condition?

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* 11. How often do you feel that your provider values your opinion or input in your healthcare treatment plan?

Example: Your provider asks for your thoughts/concerns before starting a new medication or ordering tests.

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* 12. In the last 12 months, have you gone to a hospital emergency room for a non-life-threatening condition that lasted 2-3 days or more?

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* 13. If yes, what factors did you consider when making the decision to go to the hospital emergency room over going to a local urgent care center? (Check all that apply)

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* 14. Did you try to contact your provider's office prior to going to the Emergency Room?

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* 15. If your provider started offering Virtual Visits (a visit type performed electronically via a service similar to Skype/FaceTime), what type of visit would you be interested in having virtually instead of in-person?

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