Patient Feedback Request

Patient feedback / outcome information is available for purposes of quality review and education only - any and all information is considered to be confidential.
 
Gold Cross will keep 1 contact name and email on file per service (service Training Officer) and all requests for feedback will be routed securely through that contact - Only members that rendered care to a patient are able to request/receive information.  If your group is not affiliated with Gold Cross please put in your directors information.

All requests for patient feedback must be accompanied by a faxed run sheet ATTN: Nick Romenesko to 920-727-3033.  

Each group may request feedback on each patient no more than 2 times.  

If any requests for feedback are needed for a CISD, please contact Gold Cross Dispatch immediately at 920-727-3034 to initiate the CISD response and ask them the page Nick Romenesko for urgent patient feedback.  

For all other requests, please allow a minimum of 48 hours for response. 

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* 1. Name of person requesting feedback

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* 2. Training Officer Information

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* 4. What was the Date and Time of the Call?

Date / Time

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* 5. Call Information ( Dispatch Address )

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* 6. Please select the reason you want patient feedback / outcome information.

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* 7. Other Information or Comments:

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* 8. Run Report Upload

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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