Form CMS-10169 Beneficiary Survey (English Language Version)

DEPARTMENT 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

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N/A

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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

□

□

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