Strongly Agree Disagree Strongly Not
1. In regards to this survey, which office are you reporting on?
Select Office
56 Thomas Johnson Drive
63 Thomas Johnson Drive
Ballenger Creek
Brunswick / Jefferson
Spring Ridge
Urbana
Walkersville
Woodsboro
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2. Please enter the date of the visit you are reporting.
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3. I was able to schedule my appointment for this visit within a reasonable amount of time.
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4. When I called the office during regular office hours, I received the help or advice I needed.
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5. If I had to leave a message, I received a call back that same day.
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If "No", what was the unreturned call regarding?
-- Select one --
Appointment
Billing
Insurance
Lab Reports
Medical Records
Referrals
Refills
Nurse Question
Other
6. The front office staff met and greeted me promptly and courteously.
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7. The nursing staff greeted me promptly and courteously.
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8. The nurses spent an appropriate amount of time with me to understand and communicate my medical needs.
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9. How many minutes did you have to wait to see the provider?
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10. The provider listened to me and my problems and showed respect and concern for what I had to say.
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11. The provider explained things in a way I could understand.
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12. The provider spent enough time with me at this visit to discuss the problem I came in for.
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13. Which provider did you see?
Please Select Provider
Haroon Akhtar, MD
James Amerena, M.D.
Gene Ashe, M.D.
Joseph Ashwal, M.D.
Janet Ciarkowski, M.D.
Vivian Dechosa, M.D.
Gerard DelGrippo, M.D.
Jill Durfee, M.D.
Edward Fisher, M.D.
J. Christopher Fleming, M.D.
Caroline Gessert, M.D.
Richard L. Gough, M.D.
Dale Heitzig, M.D.
Rebecca Herman-Smith, D.O.
Chan-hing Ho, M.D.
Karen Hundemer, M.D.
Amy Jones, M.D.
Diana Juliano, M.D.
Diana Juliano, M.D.
Leonard Kinland, M.D.
Stephen Lee, M.D.
Michael Lerner, M.D.
Nabila Shad, M.D.
Hanna Siwiec, M.D.
Kathleen Stern, M.D.
Virginia Wiley, M.D.
Virginia Wiley, M.D.
Deborah Austill, P.A.-C
Emily Bagby, P.A.-C
Amanda Bailey, C.R.N.P.
Susan Burton, C.R.N.P.
Maureen DeGrange, C.R.N.P.
Heather Demory, P.A.-C
Jenni Dorsey, P.A.-C
Rebecca Earley-Lee, P.A.-C
Kerry Edwards, P.A.-C
Robyn Fowler, C.R.N.P.
Tamara Moreland, C.R.N.P.
David Newlin, P.A.-C
Justina Olsen, P.A.-C
Jennifer Teeter, P.A.-C
Constance Wantling, C.R.N.P.
Rose Wienhoff, C.R.N.P.
Elizabeth Wilson, P.A.-C
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14. When I checked out, the staff member collected my payment, or explained the insurance billing if needed.
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15. If I received a referral to a specialist at my visit,
it was handled in a timely manner and to my satisfaction.
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16. I would recommend your facility to others.
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17. I was satisfied with the service from FPCA staff
and my provider and the overall quality of my visit.
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18. I am insured by:
Please Select Insurance
Aetna
BlueChoice HMO
BlueCross BlueShield Federal Employee Program
CareFirst BlueCross BlueShield
Cigna
Coventry Health Care
First Health
Great-West Healthcare
Humana/ChoiceCare
Johns Hopkins HealthCare
M.D.IPA HMO
MAMSI Life & Health
Medicare
MultiPlan
National Capital PPO (NCPPO)
OneNet PPO (formerly Alliance PPO)
Optimum Choice HMO
Private Healthcare Systems (PHCS)
United Healthcare
Other Insurance
Self Pay - No Insurance
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19. I am satisfied with the level of service provided by my insurance plan.
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20. I am:
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22. My comments or suggestions for improvement of my visit are:
* - denotes required fields
