Employee Health Benefits Feedback Form

We value your opinion and comments concerning the employee benefits available to you and your family. With your honest feedback, we can make changes that ultimately improve your healthcare experiences and quality of life.

While it is purely optional, you can choose to leave your contact information at the end of this form. That way, we can reach out to you regarding your comments or suggestions. Please allow up to five business days for us to respond.
Select the benefit for which you would like to leave feedback. To leave feedback for multiple benefits options, please submit a separate form for each one.

Health Insurance (BCBSLA)TeladocNurse Line/Care ManagementDietitianEmployee Assistance Program (BHS)Critical Support Intervention (CSI)Other
Select the benefit(s) below for which you would you like to leave feedback.

Health Insurance (BCBSLA)Flexible Spending Accounts (FSA)Prescriptions (Express Scripts)Health Savings Account (HSA)Dental Insurance (Delta Dental)TeladocVision Insurance (Ameritas/VSP)Supplemental Benefits (Aflac)Basic Life InsuranceAccidental Death & DismembermentOptional Life Insurance (Lincoln)Short- or Long-Term DisabilityEmployee Assistance Program (BHS)Wellness ProgramsCritical Support Intervention (CSI)401(k)/ESOP (Principal)LegalShield/IDShieldPet Insurance (Nationwide)Discounts (Abenity)Awards & RecognitionVacation/Sick LeaveOther
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Which health plan do you want to rate?

Base PlanHigh Deductible Health Plan (HDHP)Other

How satisfied are you with this benefits option overall?

	1	2	3	4	5

1 is Worst, 5 is Best

Would you recommend this benefit plan/provider to a friend?

YesNo
Why not?
Do you have any questions about this benefit?
Please leave feedback about your experience working with this benefit. If it did not meet your expectations, please be specific about how we can improve this benefit.

How satisfied are you with the amount you pay PER PAYCHECK for this plan?

	1	2	3	4	5

1 is Worst, 5 is Best

How satisfied are you with the amount you pay in copays, deductibles or other out-of-pocket expenses because of this plan?

	1	2	3	4	5

1 is Worst, 5 is Best

How satisfied are you with quality of care you receive on this plan?

	1	2	3	4	5

1 is Worst, 5 is Best

How satisfied are you with the in-network options you have on this plan?

	1	2	3	4	5

1 is Worst, 5 is Best

Do you plan to keep this plan the next time you have the chance to change it?

YesNo
Why not?
Do you have any additional comments or feedback?
Thank you. Would you like for an HR rep to contact you about your submission?

Yes, I'd like to provide my name and contact information.No, I'd prefer to remain anonymous.
Name*

Patient's First NamePatient's Last Name
E-mail*
Phone Number*
Should be Empty:

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