Frontera - Patient Complaint / Comments

Frontera Patient Compliment / Complaint Form

Your Name:

Date of Service:

Physician's Name:

Practice Name:

Relationship to Patient:

Self Spouse Parent Dependent Child Legal Guardian

Patients Name:

Compliment / Complaint:

Is your concern about billing?:

Yes No

Is your concern about patient care?:

Yes No

Did you discuss your concern with the technician?:

Yes No

Did you discuss your concern with your physician or practice staff?:

Yes No If yes, who:

Nature of your comment

Please check the boxes below which best describe the nature of your comment.

Compliment

Quality of Medical Care

Outstanding Customer Service

Superior Facilities

Staff Assistance / Support

Timely Problem / Issue Resolution

Friendly & Courteous Staff

Caring & Compassionate

Other / Additional Comments:

Complaint

Substandard Care (i.e. misdiagnosis; negligent treatment; delay in treatment; improper referral)

Unprofessional Conduct (i.e. breach of privacy or confidence; record alteration; provider impairment)

Technician (inattentive, rude or abusive behavior; failure to adequately address patient needs)

Substandard Facilities or Equipment (cleanliness concerns; cluttered; equipment inoperative)

Scheduling or Appointment Issues (difficulty scheduling; not timely; no same-day available)

Other / Additional Comments:

Regarding this comment, I wish to be contacted in the following manner:

	Email Phone Mail Do Not Contact Me
Email:
Phone:
Best Time To Call:
Mailing Address:
City, State, Zip:

Additional Comments:

Filing a compliment or complaint is strictly voluntary; however, without the information requested above, we may be unable to adequately process your comment. We collect this information under the authority of the Privacy Rule issued pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPPA). We will use the information you provide to determine how we will process and/or respone to your comment.

Information submitted on this form is treated confidentially. Names or other identifying information about individuals are disclosed when it is necessary for investigation of health-related matters, possible health information privacy violations, for internal systems operations, or for routine use, including disclosure for purposes associated with health information and privacy compliance as permitted by law.

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