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.  
All requests for patient feedback must be accompanied by a faxed run sheet ATTN: Samantha Hilker 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 Samantha for urgent patient feedback.  
For all other requests, please allow a minimum of 48 hours for response. 

* 1. Name of person requesting feedback

* 2. Training Officer Name

* 3. Training Officer e-mail

* 5. What was the date of service?

* 6. What was the dispatch address?

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

* 8. Comments: 

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