Please select the region associated with your comment, concern, or inquiry.
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Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship to Patient
*
Self
Spouse/Partner
Parent
Child
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Provider's Area of Practice
*
Northern California: Providence Medical Group
Southern California: St. Joseph Heritage Medical Group
Southern California: St. Jude Heritage Medical Group
Southern California: Mission Heritage Medical Group
Southern California: St. Mary High Desert Medical Group
Southern California: Providence Affiliated Physicians, St Joseph
Southern California: Providence Affiliated Physicians, St Jude
Southern California: Providence Affiliated Physicians, Mission
Southern California: Facey Medical Group
Southern California: Saint John’s Physician Partners
Southern California: Providence Medical Associates/Axminster
Southern California: Other- Los Angeles
City of Provider's Medical Office
*
Provider's Name
*
First Name
Last Name
Suffix
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Patient's Name
*
First Name
Middle Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Phone Number
*
Please enter a valid phone number.
Patient's Email
*
example@example.com
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Nature of Comment/Concern/Inquiry (Choose all that apply)
*
Appointment Availability
Phone
Physician/Provider
Staff
Quality of Care
Lab or Test Results
Health Plan/Insurance
Referral/Authorization
Medication/Prescription Refill
Billing
Privacy/Security
Environment/Facilities
Safety
Compliment
Date of Occurrence
*
-
Month
-
Day
Year
Date
Name of Witness(es)
Explanation of Comment/Concern/Inquiry
*
Suggested Resolution
*
Do you wish to be contacted? If yes, correspondence will be initiated by email and if necessary, a phone call appointment is scheduled
*
Yes
No
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