(Toll-Free) (1-800) 655-3666

MD Satisfaction Survey

Doctor's Name: Date:
Telephone Number:
Patient's Name: SOC:
    MR#:
Yes/No
1. Was the Intake Coordinator prompt in taking calls? Yes No
2. Were you involved in formulating the Plan of Care? Yes No
3. Were you promptly notified of significant changes in your patient's condition? Yes No
4. Were we prompt and dependable in returning your telephone call? Yes No
5. Are you satisfied with the care we have provided your patients? Yes No
6. From a scale of 1-5 (1 being low and 5 being high), how would you rate the services we provide to you and your patients?
7. How can we improve our services?

AFHOLA
Association of
Freestanding Home Health
Agency Owners of Los Angeles