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Physician Name / Clinic:
Date (Month/Day/Year):
Our goal is to provide exceptional medical care to all injured/ill employees who use the MetraComp Preferred Provider Network. We would like to know your thoughts about our physicians and hospitals. Your comments will help us to provide a better service. Thank you so much for your time.
1. What type of job do you perform?
2. Before you were injured or became ill, did your company provide you with information about the MetraComp Preferred Provider Network? If so, how was that information provided?
EE Handbook
Brochure/Letter
Company Representative
Other
3. What was the nature of your visit?
4. Where did you go for medical treatment?
5. Did your doctors ask you about or have access to your job-related duties or tasks?
6. Did your doctor provide you with information about your injury or illness?
7. If you received a follow-up appointment, what type of doctor did you see?
7a. How would you rate the care that you received?
8. Was your visit of an urgent nature?
8a. If yes, how long did you wait to be seen after your arrival?
Less than 15 minutes 15 to 30 minutes
8b. If not of an urgent nature, how long did you have to wait to be seen after your arrival?
First Treatment Less than 15 minutes 15 to 30 minutes More than 30 minutes
9. After your appointment, were you released to return to work?
First Treatment Yes, to my regular job Yes, but to a modified/light job No Not Applicable
10. How many appointments did you have before you returned to work?
11. Did the MetraComp provider that you called for an appointment accept workers' compensation patients?
11a. If yes, and this was your initial appointment, how many days did you have to wait for your appointment?
11b. If yes, and this was a follow up appointment, how many days did you have to wait for your appointment?
11c. If no, how many providers did you have to call?
12. If there is any way that we can improve our service to you, please tell us about it.
