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pdfDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
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
1. ARRANGING FOR EQUIPMENT
How would you rate your initial interaction with the DME
supplier from which you recently received your DME?
N/A
□
N/A
□
4. EQUIPMENT QUALITY
N/A
□
VERY
POOR
FAIR
□
6. OVERALL COMPLAINT HANDLING
GOOD
□
□
□
VERY
POOR
FAIR
□
□
□
VERY
POOR
FAIR
□
□
□
VERY
POOR
FAIR
VERY
□
GOOD
□
VERY
GOOD
□
GOOD
□
VERY
GOOD
□
GOOD
□
VERY
GOOD
□
□
□
VERY
POOR
FAIR
□
□
□
□
GOOD
□
GOOD
POOR
□
VERY
GOOD
□
POOR
N/A
How would you rate the DME supplier’s overall
complaint handling?
□
POOR
□
5. CUSTOMER SERVICE
How would you rate the customer service provided by
the DME supplier?
□
GOOD
POOR
N/A
How would you rate the quality of the DME provided by the
DME supplier?
FAIR
POOR
3. DELIVERY OF EQUIPMENT
How would you rate your experience with the DME
supplier concerning delivery of the DME?
POOR
POOR
□
2. TRAINING
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?
VERY
□
VERY
GOOD
□
□
_______________________________________________________________________________________________________________________________
Form CMS-10169D (07/09) EF(07/2009)
| File Type | application/pdf |
| File Title | Microsoft Word - RFB Form D PAOC and technical changes 5 5 10(english) |
| Author | es49 |
| File Modified | 2014-03-27 |
| File Created | 2014-03-26 |