Member Survey

Community Health Alliance

Member Survey

CHA is proud to offer you a network of carefully selected physicians, hospitals and other healthcare providers. Your input provides feedback and measurements of satisfaction so that we can better serve you. Please take a few moments to answer the following questions about your provider office visit. Your comments are appreciated and valuable to us in helping to meet the needs of all our members.

Please rate the following aspects of your visit.

Physical accessibility

Very Poor Poor Fair Good Very Good

General appearance of the waiting and exam room

Very Poor Poor Fair Good Very Good

Exam room space

Very Poor Poor Fair Good Very Good

Adequacy of waiting time to see provider

Very Poor Poor Fair Good Very Good

Availability of scheduling an appointment with your provider

Very Poor Poor Fair Good Very Good

If you ranked the availability of scheduling an appointment with your provider as "Fair" or below, was the issue resolved at the time of your appointment?

Yes No N/A

Comments

Provider Information

Provider Office Name

Provider Name

Your Information

Your Name

Employer Name

Date of Office Visit

Date Picker

Thank you for your participation in this survey.