Tell us about your recent visit with your provider.
Survey template · 11 fields (7 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your cahps clinician & group survey
Tell us about your recent visit with your provider.
Send within a few weeks of the visit and keep responses anonymous by default. Use a HIPAA-appropriate setup; official CAHPS reporting requires an approved survey vendor.
The form separates provider's name, date of your visit (optional), did you get an appointment as soon as you needed?, did this provider explain things in a way that was easy to understand? into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Send within a few weeks of the visit and keep responses anonymous by default. Use a HIPAA-appropriate setup; official CAHPS reporting requires an approved survey vendor.
Customize the provider's name and date of your visit (optional) questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Your name (optional) (Name)
Email address (optional) (Email)
Provider's name (Short text, required) — The doctor, nurse practitioner or physician assistant you saw.
Date of your visit (optional) (Date)
Did you get an appointment as soon as you needed? (Single choice, required)
Did this provider explain things in a way that was easy to understand? (Single choice, required)
Did this provider listen carefully to you? (Single choice, required)
Did this provider show respect for what you had to say? (Single choice, required)
Were the front desk staff helpful and courteous? (Single choice, required)
Overall rating of this provider (Dropdown, required)
Comments about your visit (optional) (Long text)
Frequently asked questions
What does this cahps clinician & group survey template collect?
Alongside contact details, it asks for provider's name, date of your visit (optional), did you get an appointment as soon as you needed?, did this provider explain things in a way that was easy to understand?, did this provider listen carefully to you?, did this provider show respect for what you had to say?, were the front desk staff helpful and courteous?, overall rating of this provider, comments about your visit (optional). You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this cahps clinician & group survey form?
Send within a few weeks of the visit and keep responses anonymous by default. Use a HIPAA-appropriate setup; official CAHPS reporting requires an approved survey vendor.
Can I edit this form and print a copy?
Yes. Open an editable draft, adjust the questions, and review the preview before publishing. You can also use the template page’s print option. Publishing requires an account; the draft can be tried first.