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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