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Survey

Please complete all of the questions in this survey so we can process your guide.  If you have any questions about these questions, please do not hesitate to give us a call.

* Means this is a required field
 
   1.  What is the "Public" name of your business?
(What company name do you use in your marketing, signage, letterhead and other references?)

   2.  Does your company have a different "Legal" name? If so, what is it?

   3.  What is the legal structure of your business?


   4.  In what state was your company legally formed?

   5.  Who is responsible for the company's day-to-day function?

   6.  Please list any persons with a 5% or greater ownership of the company:

   7.  Who is on the governing body of the company?

   8.  Does your company provide a benefit program?
   9.  What is the complete STREET address of your PRIMARY location? (City St Zip)

   10.  What is the complete STREET address of your SECONDARY location?

   11.  What is the complete STREET address of your TERTIARY location?

   12.  What is the company's guideline for contacting new patients within a certain number of days of patient referral?
(If you do not currently have a policy, please choose from an answer below.)

   13.  Does the company administer patient satisfaction surveys?
   14.  How frequently is the patient satisfaction survey data compiled and reviewed?
(If you do not currently have a policy, please choose from an answer below.)

   15.  Does the company administer a Performance Management Program?
   16.  How frequently is the Performance Management data compiled and reviewed?
(If you do not currently have a policy, please choose an answer below.)

   17.  How frequently does the company conduct chart audits?
(If you do not audit, how frequently do you INTEND to audit?)
   18.  Who is responsible for the company's Safety Management program?

   19.  What is the best telephone number to reach the Safety Manager?

   20.  Is there an "Outside Vendor" that maintains your fire extinguishers? If so, what is their name?

   21.  How frequently does each office conduct fire evacuation drills?
(If you do not currently have a policy, please choose from an answer below.)

   22.  Who is responsible for the company's Supplier Compliance program?

   23.  What is the best telephone number to reach the Compliance Officer?

   24.  Who is responsible for the company's Patient Privacy program?

   25.  What is the best telephone number to reach the Privacy Officer?

   26.  Who should be contacted for "after hours" or emergencies?

   27.  What is the telephone number for "after hours" and emergencies?

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