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
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
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
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
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
CUSTOMER SERVICE POOR GOOD
How would you rate the customer service provided by □ □ □ □ □ □
the DME supplier?
N/A VERY POOR FAIR GOOD VERY
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 Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-29 |