Form CMS-10169 Form D

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-xxxx

COMPETITIVE BIDDING PROGRAM BENEFICIARY SURVEY
FORM D
Name of DME Contract Supplier — Provided by the CBIC

Type of DME — to be Provided by the CBIC

INSTRUCTIONS: Please rate the services you received from this durable medical equipment (DME) contract
supplier. Check the box that best describes your experience. If a question does not apply to you, please
check N/A.
N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

1. ARRANGING FOR EQUIPMENT
How would you rate your initial interaction with the DME
o
contract supplier from whom you recently purchased your DME?
2. TRAINING
How would you rate the training you, or the person who
takes care of you, received from the DME contract supplier
regarding the DME you recently purchased?
3. DELIVERY OF EQUIPMENT
How would you rate your experience with the DME
contract supplier concerning delivery of the DME?
4. EQUIPMENT QUALITY
How would you rate the appropriateness and quality
of the DME provided by the DME contract supplier.
5. CUSTOMER SERVICE
How would you rate the customer service provided by
the DME contract supplier?
6. OVERALL COMPLAINT HANDLING
How would you rate the DME contract supplier’s overall
complaint handling?

o

o
o
o
o

o
o

o

o
o
o

o
o

o

o
o
o

o
o

o

o
o
o

o
o

o

o
o
o

o
o

o

o
o
o

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-xxxx. The time required to complete this information collection is estimated to average 15 minutes per response, including the
time to review instructions, search existing data resources, gather the the data needed, and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Blvd. Baltimore, Maryland 21244.
Form CMS-10169D (xx/xx)