1) I am a patient of Klamath Open Door Family Practice Sprague Valley Open Door Family Practice Chiloquin Open Door Family Practice

2) My health center’s hours of operation are: Convenient Reliable Inconvenient Confusing

3) Who is your primary healthcare provider Dr. Chase Terry James Terry Jones Dr. Haas Dr. Lamanuzzi Dr. Lane Dr. Lee Dr. Mayberry Dr. Mayland Dr. Miller Dr. Rey Jeff Sewing

4)My health center’s staff is courteous, knowledgeable, and professional:     Each time I make or come in for my appointment Most of the time when I make or come in for my appointment Only sometimes when I make or come in for my appointment

5) I use my health center for:     Dental care only Medical care only Both dental and medical care

6) My healthcare insurance … Is offered and paid for by my employer Is offered by my employer but my employer doesn’t pay for it Isn’t offered by my employer Is purchased entirely by me Is paid for by a government program like Medicaid or Medicare I don’t have healthcare insurance

7)How easy is it for you to make an appointment when you need one with your primary healthcare provider
I can easily make an appointment within 1 to 2 days. I have to wait a week or more for an appointment I cannot make an appointment when I need one and need to go someplace else for my healthcare

8) If I can’t make an appointment when I need one, I usually Go to the hospital emergency room Go to an urgent care center Wait as long as I need to until an appointment is available

9) I see my primary healthcare provider   1-2 times per year 3-5 times per year 6 or more times each year   

10)I receive healthcare that is timely, safe, and of high quality from my primary healthcare provider
Yes No   

11) My bill is easy to understand 
Yes No   

12) I know who to call when I need help to understand my bill
Yes No   

13) I know about my health center’s sliding fee discount that helps me manage my healthcare costs
Yes No   

14)I am currently eligible for the sliding fee discount
Yes No Dont Know   

15) I require assistance with transportation to and from my appointment
Often Sometimes Not at All   

16) I can get help from my health center for transportation when I need it  
Often Sometimes Not at All   

17)I require assistance with the cost of medications  
Often Sometimes Not at All   

18) I can get help from my health center with the cost of medications when I need it 
Often Sometimes Not at All   

19)I require a translator for my appointment
Often Sometimes Not at All   

20)I can get help from a translator from my health center when I need it
Often Sometimes Not at All