* = Required Information

Your Name * 
Date * 
Your Organization * 
Tel. No. 
Fax No. 
Email 

Legend: (Please be guided with the below equivalent of the choices)

5 - Agree1 - Disagree

Quality/Appropriate Client Care

1. The ordered Plan of Care and follow-up instructions are followed consistently. *

1
Comments: 

2. Clients are satisfied with your home health care service.*

1
Comments: 

3. I am confident in the skills, knowledge and ability of home health staff caring for our clients. *

1
Comments: 

4. I would recommend AlliedCare Home Health to my colleagues. *

1
Comments: 
Communication/Feedback

1. I am satisfied with the communication I receive from the clinical staff about my clients. *

1
Comments: 

2. I am promptly and appropriately informed of changes in the condition of my clients. *

1
Comments: 

3. I receive timely verbal or written summaries of my client's condition. *

1
Comments: 

4. In general, I am satisfied with the communications I receive from your home health agency. *

1
Comments: 
Services

1. Adequate information regarding available services offered by your home health agency is provided. *

1
Comments: 

2. Adequate information regarding client eligibility for home health care services is provided. *

1
Comments: 

3. Ordered home care services are initiated on a timely basis. *

1
Comments: 

4. I am interested in hearing more about your services. *

1
Comments: 
How can we improve our service and/or communication?: 

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