Customer Feedback Form

POLICY: The patient, family member or legal representative, or any other external customer may report feedback at any time during or after service provided by any THA Group, Inc. provider. Any feedback may be reported without compromise to the customer's future access to services.

The company encourages reporting of any concern, complaint, or general feedback in order to continuously improve the quality of care and services – no matter how insignificant the comment may seem. Reporting is not viewed in a punitive manner and is strictly confidential.

Question Title

* THA Group Employee Who Received Feedback from Customer

Name

Email Address

Question Title

* Date/Time Feedback Reported

Date / Time

Date

Time

AM/PM

Question Title

* Customer's Service Line

Question Title

* Customer's Community Office

Question Title

* Customer Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* Feedback Category

Compliment/Praise

Financial issue

Property damage/loss

Timeliness

HIPAA issue

Issue with employee

Issue with services provided

Unmet needs

Other

Other (please specify)

Customer Feedback Form

Question Title

* THA Group Employee Who Received Feedback from Customer

Question Title

* Date/Time Feedback Reported

Question Title

* Customer's Service Line

Question Title

* Customer's Community Office

Question Title

* Customer Information

Question Title

* Feedback Category

Question Title

* Description of Feedback

Question Title

* Immediate Actions Taken