Quality Improvement Survey To be eligible for our prize drawing please complete Member's Name* Member Number* Member's DOB* Name of Provider or Location who provided service to you* When you telephoned the Doctor’s office for an appointment, how many days after your call was your appointment scheduled to see the Doctor?* Was the Doctor you chose within 60 minutes/30 miles from your home or office?* Yes No N/A How long did you wait after your appointment time to begin your eye examination?* Were you treated or referred to an M.D. for any medical condition?* Yes No N/A If yes, name of doctor If you required a medical referral, how many days was it until the referred Doctor saw you? If you had an after hours emergency, was it handled to your satisfaction?* Yes No I did not have an after hours emergency Was the Doctor's office staff polite?* Yes No N/A Was the Doctor's office staff knowledgeable about your vision benefits?* Yes No N/A Was your vision problem solved?* Yes No N/A How was Vision Plan of America's customer service?*ExcellentGoodSatisfactoryWhat languages do you prefer? Would you recommend Vision Plan of America to a friend?* Yes No N/A Refer a friend: Call (800) 400-4872 for details.Additional commentsPhoneThis field is for validation purposes and should be left unchanged.
