Comment Form — WA State NEMT

Comment Form:

Your feedback is very important to us.

Please provide specific information regarding your customer comment, complaint or compliment below. Please try to keep the information brief, but specific. All Comments are reviewed, and we will reach out if we need more information. Not all comments require call back. Please indicate below if you need further follow up and when the best time to call.

Today's Date:

YYYY

Date of Incident:

YYYY

Time of Incident:

Hour

Minute

Second

Client Name:

First Name

Last Name

Client Date of Birth:

YYYY

Client Phone Number:

(###)

###

####

If the comment is about a ride provided, please provide the following information:

Client Inbound Appointment Time:

Hour

Minute

Second

Client Return Ride Time:

Hour

Minute

Second

Please Check One:

Arrived Early

Arrived Late

Missed Appointment

Client Trip Purpose:

Client Comment:

Please provide specific information regarding your customer comment, complaint or compliment below. All Comments are reviewed, and we will reach out if we need more information.

If this is NOT the client submitting the comment, please provide the information below:

Care Providers Name:

First Name

Last Name

Care Provider Phone Number:

(###)

###

####

Relationship to Client: