Medical Survey Form

CONFIDENTIALAND PRIVILEGED/WORK PRODUCT
Employee #: *
When you called the medical section to go on the medical or IOD

Did a live person answer your call?Did you leave a voicemail?Did you get disconnected?Phone call was not answered
What is the Month & Year of your IOD or Medical Absence?

MonthDayYear
When you left a message for the medical section about your medical or IOD status, how long did it take for a response?
Did the medical section supply you with a list of referral doctors for your injury?
If you required a referral for a specialty doctor, was a doctor available on the referral list?
After you notified the medical section of your need for a referral to a specialty doctor, did you need to follow-up with the medical section by telephone or otherwise to obtain the referral?
If so, please specify the dates, time and method of communication used to follow-up with the medical sections obtain a referral?
Did the referral list have sufficient doctors to choose from in the specialty you were seeking?
How long did it take to get an appointment with a doctor for your IOD?
How long did it take to get a appointment for your physical therapy?
If your IOD required you to have surgery, how long did it take to get approval for your surgery once your doctor requested surgery?
How did you receive notification that your IOD was approved or denied?

The medical service section case manager notified meGallagher Bassett Agent called meGallagher Bassett mailed me a letter with the status of my claimI never received any notification with the status of my claim
When you first went on the medical for your IOD , how long did it take to receive a letter from Gallagher Bassett that your IOD was approved or denied?
When you went to report to the medical section for the 1st time for your IOD were you told that your claim was pending approval from Gallagher Bassett?
If your IOD claim was pending approval from Gallaher Bassett, did this delay you receiving any doctor’s appointments from the Medical Service Section?
How would you rate your overall experience with the Medical Service Section?
How would you rate your overall experience with Gallagher Bassett?
Any information collected pursuant to this survey will be kept confidential and not disclosed to any outside party to the fullest extent provided by law.
If you have any further information you would like to share with FOP, please contact Monica Ortiz FOP Lodge 7 Field Representative mortiz@chicagofop.org
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CONFIDENTIALAND PRIVILEGED/WORK PRODUCT

Any information collected pursuant to this survey will be kept confidential and not disclosed to any outside party to the fullest extent provided by law.

If you have any further information you would like to share with FOP, please contact Monica Ortiz FOP Lodge 7 Field Representative mortiz@chicagofop.org