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Claimant Quality Survey    Please note that each Crossland file number represents one Independent Medical Exam. Your Crossland file number is located at the top of each appointment letter. If you would like to provide feed back for multiple exams please submit one from for each Crossland file number/ Independent Medical exam. If you have any questions or need additional information please call 1-800-335-0975 or email claimant_serv@crosslandmed.com Supporting Details Submitting Party Name: Email Address: Crossland File # Claim # Please respond on a scale of 1 to 5:                1                                2                               3                     4                          5          Dissatisfied      Somewhat Dissatisfied          Neutral           Satisfied                Very Satisfied Customer Service:  How satisfied were you with the Crossland representative’s speed and knowledge? 1 2 3 4 5 How satisfied were you with the necessary details provided to you regarding the independent medical exam by the Crossland representative? 1 2 3 4 5 If it was necessary for a Crossland representative to follow-up with you was it timely? Yes No Did you request to have your Independent medical exam time or location changed? Yes No If yes, were you accommodated? Yes No Did the Crossland representative help you resolve the situation to your satisfaction? Yes No How satisfied were you with Crossland’s customer service representative’s professionalism and courtesy? 1 2 3 4 5 Were you furnished with directions to the exam location? Yes No How satisfied were you with the Crossland representative’s explanation regarding why you needed to attend and who requested the Independent Medical Exam? 1 2 3 4 5 Were you notified by mail of the appointment? Yes No Were you called to confirm the appointment a few days before? Yes No How satisfied were you with the overall experience with Crossland? 1 2 3 4 5 How satisfied were you with the overall Independent Medical Exam Quality? 1 2 3 4 5 Were you informed that the Independent Medical Exam request by you insurance company did not constitute a relationship with the examining health care provider? Yes No Were you explained what the purpose of the exam was? Yes No Did the examining health care provider take a history during the evaluation? Yes No During the IME did examining health care provider take notes as you talked about you condition? Yes No Were you asked how you became injured or about the onset of the illness? Yes No How satisfied were you with the professionalism of the examiner? 1 2 3 4 5 How long was the duration of the examination?     Do you feel that you were examined comprehensively? Yes No Examining Office: How satisfied were you with the office staff? (Were they professional and helpful?) 1 2 3 4 5 How satisfied were you with the time you had to wait to be examined? 1 2 3 4 5 How satisfied were you with the examining office? (Was the waiting area clean and professional?) 1 2 3 4 5 Please indicate your overall satisfaction with the experience 1 2 3 4 5 Please tell us how to improve. Do you have any suggestions that would have made your experience or our process a better?