CUSTOMER HMO FEEDBACK FORM

CUSTOMER HMO FEEDBACK FORM
Date

MonthDayYear
Date
Company Name
Surname - First Name - Other Names
Enrollee Name*
Surname - First Name - Other Names
Telephone*
Email*
Organization*
Enrollee ID*
What is your assessment of our services?*

ExcellentVery GoodGoodFairPoor
Were you attended to promptly?*

YesNo
How long did it take to resolve your issue?*

2 Mins5 Mins10 Mins15 MinsMore than 20 Mins
Are you in the know of how issue is being resolved?*

Yes, I was carried alongNo CommunicationI was abanonded
What is the body language of the attending Officer?*

ProfessionalUnprofessionalFriendlyRudeGood Communicator
Can you give Alleanza HMO referral to others?*

YesNo
If No, Pease give reason
General comment/Suggestions
Should be Empty: