Patient Feedback Request

The TriStar Health patient outcomes query system is designed to provide relevant clinical outcomes data to our clinical partners as a resource for quality improvement initiatives. Information shared must be between covered entities that have a current or prior relationship with the patient in question. Appropriate clinical information sharing can improve EMS and health system performance and the provision of quality care.

Please allow up to 72 hours for a response to your request.

All fields with an asterisk (*) are required.

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2020-TS-Tristar Patient Feedback Request-PHI

Person requesting feedback*

First Name

Last Name

E-mail*

Phone Number*

Preferred method of communication*

EMS Agency or Hospital Affiliation Name

Date of Service*

Patient Initials*

Patient Date of Birth*

Sending Facility

Sending Facility Phone Number

Receiving Facility*

Comments

This program is compliant and references the following HIPAA Rules: 45 CFR 160.103, 164.501, and 164.506(c)(4).

Average ER Wait Times

Patient Feedback Request

Thank You