Form CMS-10169 Form D - Survey

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

Form Approved

OMB No. 0938-xxxx

COMPETITIVE BIDDING PROGRAM

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 contract suppliers. Check the box that best
describes your experience. If a question does not apply to you, please skip to the next question.
1. ARRANGING FOR EQUIPMENT
How would you rate your initial interaction with the DME
contract supplier that you recently purchased your DME from?

N/A

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VERY
POOR

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POOR

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FAIR

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GOOD

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VERY
GOOD

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?

N/A

❏

VERY
POOR

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POOR

❏

FAIR

❏

GOOD

❏

VERY
GOOD

3. DELIVERY OF EQUIPMENT
How would you rate your experience with the DME
contract supplier concerning delivery of the DME?

N/A

❏

VERY
POOR

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POOR

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FAIR

❏

GOOD

❏

VERY
GOOD

4. EQUIPMENT QUALITY
How would you rate the use of the DME provided by the
DME contract supplier.

N/A

❏

VERY
POOR

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POOR

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FAIR

❏

GOOD

❏

VERY
GOOD

5. CUSTOMER SERVICE
How would you rate the customer service provided by
the DME contract supplier?

N/A

❏

VERY
POOR

❏

POOR

❏

FAIR

❏

GOOD

❏

VERY
GOOD

N/A

VERY
POOR

POOR

FAIR

GOOD

VERY
GOOD

6. OVERALL COMPLAINT HANDLING
How would you rate the DME contract supplier’s overall
complaint handling?

Form CMS-10169D (xx/xx)

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