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    Member Name


    Plan / Group Number


    Practioner Name



    Facility Rating
    5 (Excellent)
    4
    3 (Average)
    2
    1 (Poor)

    Comments on Facility


    Staff Rating
    5 (Excellent)
    4
    3 (Average)
    2
    1 (Poor)

    Comments on Staff


    Provider Rating
    5 (Excellent)
    4
    3 (Average)
    2
    1 (Poor)

    Comments on Provider


    Clarification of Problem
    5 (Excellent)
    4
    3 (Average)
    2
    1 (Poor)

    Comments on Clarification of Problem