Form CMS-10169 Beneficiary Survey

Requests for Bids (RFB) for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program

Form D_2012

Round 1 Re-Compete for the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program; Beneficiary Survey (Form D)

OMB: 0938-1016

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DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-1016


MEDICARE DMEPOS COMPETITIVE BIDDING PROGRAM


Name of DME Supplier – Provided by the CBIC



Type of DME – to be Provided by the CBIC













INSTRUCTIONS: Please rate the services you received from your DME supplier. Check the box that best describes your experience. If a question does not apply to you, please skip to the next question.


N/A VERY POOR FAIR GOOD VERY

  1. ARRANGING FOR EQUIPMENT POOR GOOD

How would you rate your initial interaction with the DME □ □ □ □ □ □

supplier from which you recently received your DME?


N/A VERY POOR FAIR GOOD VERY

  1. TRAINING POOR GOOD

How would you rate the training you, or the person who □ □ □ □ □ □

takes care of you, received from the DME supplier

regarding the DME you recently received?


N/A VERY POOR FAIR GOOD VERY

  1. DELIVERY OF EQUIPMENT POOR GOOD

How would you rate your experience with the DME □ □ □ □ □ □

supplier concerning delivery of the DME?


N/A VERY POOR FAIR GOOD VERY

  1. EQUIPMENT QUALITY POOR GOOD

How would you rate the quality of the DME provided by the □ □ □ □ □ □

DME supplier?

N/A VERY POOR FAIR GOOD VERY

  1. CUSTOMER SERVICE POOR GOOD

How would you rate the customer service provided by □ □ □ □ □ □

the DME supplier?


N/A VERY POOR FAIR GOOD VERY

  1. OVERALL COMPLAINT HANDLING POOR GOOD

How would you rate the DME supplier’s overall □ □ □ □ □ □

complaint handling?








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Form CMS-10169D (07/09) EF(07/2009)


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCMS
File Modified0000-00-00
File Created2021-01-29

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