Primary Care Patient Satisfaction SurveyPatient Satisfaction Survey, NLH Provider ClinicsThank you!Contact InformationThis field is hidden when viewing the formEvent IDPlease enter your first and last name.(Required) First Last Please enter your date of birth.(Required) MM slash DD slash YYYY Phone(Required)What is your Primary Insurance Plan?(Required)Please select1199 SEIU Benefit and PensionAetnaBlue Cross Blue Shield Empire Blue CrossBlue Cross Blue Shield ExcellusBS HighmarkCDPHPCignaCharity CareCommerical Insurance OtherChamp VAEmblem Health GHIFidelisHumanaLifetime Benefity SolutionsMagna-CarerMedicaidMedicareMVPSelfpayTotal Plan ConceptsTricareEmpire PlanUnited HealthcareUMRUnicareUS Family Health PlanVA - Veterans AffairsWellcareOtherIs your insurance a Medicaid/Medicare plan?(Required) Medicaid Medicare NeitherProvider InformationWhat location were you seen at?(Required)Please selectAmsterdam Primary/Specialty CareBroadalbin Primary/Specialty CareCaroga Lake Primary CareFonda Primary CareGloversville CardiologyGloversville General SurgeryGloversville UrologyGloversville Neurology & Women's HealthGloversville PediatricsGloversville Primary/Specialty CareJohnstown Primary CareKingsboro GastroenterologyMayfield Primary CarePerth Primary/Specialty CareSpeculator Primary careSteele Ave Audiology & Otolaryngology (ENT)What provider (doctor) did you see during your last appointment?(Required)Please selectAlison Elsheikh, FNPAngela Fraumane, FNPArturo Miranda-Gelpi, MDDanielle Tortorici, RPA-CJames Cimo, MDJennifer Davis, PAJoseph Carrozza, MDRobert Biewala, RPA-CSowmya Chandra Reddy, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectDevarajan Manu, MDSamantha Relyea, PAYahaira Myers, FNPWhat provider (doctor) did you see during your last appointment?(Required)Please selectAlison Townsend, PAWhat provider (doctor) did you see during your last appointment?(Required)Please selectHaley Szczepanik, FNPShannon Knapp, FNPVitina Ruffino-Mosher, FNPWhat provider (doctor) did you see during your last appointment?(Required)Please selectAlexandra Mazzariello, PA-CSyed Iqbal, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectMarianna Dubovska, DONicholas Filippone, MDOsama Essa, MD Robert Wasiczko, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectAllyson Gallup, PAPaul Husson, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectGabor Zoltay, MDHenry Stephen, MDJeanine Hess, FNPJulie Tesi, CNMKaren West, WHNPKelly Priddle, CNMPatricia Nguyen, MDPeter Dowling, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectKrista Sheils, FNPMaruthi Sunkara, MDNimitariye Princewill, MDRichard Solby, DOWhat provider (doctor) did you see during your last appointment?(Required)Please selectAswathi Mathew, MDDevarajan Manu, MDDiana Sherman, MDKaren McCrea, FNPKaruna Narala, MDKayla Putman, FNPKevin Wieczenski, FNPKristyn Spencer, FNPLara Zwijacz, FNPMary Zayaz, PANicole Higgins, PAPayel Ghosh, MDSarah Hand, PATammy Capone, NPWhat provider (doctor) did you see during your last appointment?(Required)Please selectBetina Courtens,FNPCrystal Baker, PAJanis Freeman, NPStacey Vanbuskirk, PAWhat provider (doctor) did you see during your last appointment?(Required)Please selectAshlee Podolec, FNPDavid Cohen, MDHadi Minhas, MDJill Hoffman, PAShri Verma,MDSyed Zainul-Abideen, MDWhat provider (doctor) did you see during your last appointment?(Required)Please selectArunmozhi Dominic, MDKelly Viscosi, PAWhat provider (doctor) did you see during your last appointment?(Required)Please selectAubrey Mendoza, PA WHCherryl Premdass, MDChristine Holz, PAClara Shnaidman, MDDavid Eisenberg, MDJames Hopper, PAJan Carstens, MDKortney Smith, RPA-CLindsay Meadows, FNPLisa Morris, WHNPSean Ryan, MDTara Harbeck, DPMWhat provider (doctor) did you see during your last appointment?(Required)Please selectCarla Darrow, FNPMary Zayaz, PAWhat provider (doctor) did you see during your last appointment?(Required)Please selectAmy Paddock, NPBradley Paddock, MDDiana Page, DOMark Caffrey, AuD.Vassandra Murray, FNPWhen was your last appointment?(Required) MM slash DD slash YYYY We wish to ensure that you have an excellent experience as a patient at Nathan Littauer Primary/Specialty Care. Keeping in mind your visit with the provider you just saw today, how would you rate the following below? Please note that if "Excellent" is not chosen, it is an indication we have things which need improvement.1. Appointment(s) available within a reasonable amount of time.(Required) Excellent Good Poor1A. (If not excellent, what would be needed for you to provide excellent feedback?) Please select issue if not excellent. 90+ days for new patient Multiple reschedules Waited 8+ weeks for physical/annual More than 24 hours for sick appointment More than 4 weeks to reschedule a follow-up appointment2. The days and times you are offered for appointments are:(Required) Excellent Good Poor2A. (If not "Excellent," what would you suggest?) If times are an issue, please note your appointment time and day of the week. Hours: Minutes AMPM AM/PMDay(s) of the week:What would you suggest for your appointment time(s)? Later times Earlier times A different day of the weekWere you asked what time or day works best for you, when making an appointment? Yes No3. The personal manner of the provider or staff that you saw is/was:(Required) Excellent Good Poor4. My provider clearly explained any follow up needed from today’s visit, including: any communication with specialists, labs or imaging ordered, changes in medication, and/or the next appointment.(Required) Excellent Good PoorPlease tell us how we can improve any issues you were not able to provide an EXCELLENT response to:Δ
