Get actionable feedback on prior authorization delays. This customizable patient survey template tracks wait times, insurance approval issues, and care impacts.
What's Included
AI-Powered Questions
Intelligent follow-up questions based on responses
Automated Analysis
Real-time sentiment and insight detection
Smart Distribution
Target the right audience automatically
Detailed Reports
Comprehensive insights and recommendations
Template Overview
22
Questions
AI-Powered
Smart Analysis
Ready-to-Use
Launch in Minutes
This professionally designed survey template helps you gather valuable insights with intelligent question flow and automated analysis.
Sample Survey Items
Q1
Multiple Choice
In the past 12 months, have you needed prior authorization for care or medication?
Yes, within the last 3 months
Yes, 3–12 months ago
Yes, more than 12 months ago
I have never needed prior authorization
Not sure
Q2
Multiple Choice
Which types of services required prior authorization? Select all that apply.
Prescription medication
Imaging (e.g., MRI, CT)
Specialist visit
Surgery or procedure
Durable medical equipment
Lab tests
Not applicable
Q3
Multiple Choice
Who primarily handled the prior authorization request?
Doctor or clinic staff
Me (the patient)
Health insurance plan
Pharmacy
Don’t know
Not applicable
Q4
Multiple Choice
Which channels were used for the prior authorization process? Select all that apply.
Phone calls
Patient portal messages
Paper forms
Fax
In person at the clinic
Email
Insurer website or app
Pharmacy system or app
Not applicable
Q5
Multiple Choice
What was the outcome of your most recent prior authorization?
Approved without changes
Approved with an alternative (e.g., different drug/test)
Approved after appeal
Denied
Still pending
Don’t know / Not sure
Not applicable
Q6
Opinion Scale
How clear were the prior authorization requirements and steps?
Range: 1 – 10
Min: Very unclearMid: NeutralMax: Very clear
Q7
Multiple Choice
Attention check: To confirm you are paying attention, please select "Yes".
Yes
No
Not sure
Q8
Multiple Choice
If there was a delay, how long did it take from request to decision?
No delay (same day)
1–3 days
4–14 days
15–30 days
Over 30 days
Still pending
Not applicable
Q9
Matrix
How much did the prior authorization process affect you in the following ways?
Rows
Not at all
Slightly
Moderately
Quite a bit
A great deal
Postponed or rescheduled care
•
•
•
•
•
Paid out-of-pocket temporarily
•
•
•
•
•
Symptoms worsened while waiting
•
•
•
•
•
Emotional stress or anxiety
•
•
•
•
•
Missed work or school
•
•
•
•
•
Changed medication or treatment
•
•
•
•
•
Q10
Ranking
Rank the most frustrating parts of prior authorization from most to least frustrating.
Drag to order (top = most important)
Not knowing the request status
Repeating information or forms
Long phone wait times
Conflicting information between insurer and provider
Last-minute denials or changes
Difficulty reaching the right person
Q11
Multiple Choice
What helped most during the process? Select all that apply.
Clear instructions from my provider
A staff member handled it for me
Automatic status updates
Support with appeals
Financial assistance or copay card
Dedicated phone line or team
None of these
Q12
Long Text
If you could change one thing about prior authorization, what would it be?
Max 600 chars
Q13
Numeric
About how many total hours did you (or a caregiver) spend on your most recent prior authorization (calls, forms, follow-up)? Please enter a number.
Accepts a numeric value
Whole numbers only
Q14
Dropdown
What is your age?
18–24
25–34
35–44
45–54
55–64
65+
Prefer not to say
Q15
Multiple Choice
How do you describe your gender?
Woman
Man
Non-binary
Another gender identity
Prefer not to say
Q16
Dropdown
Where do you live?
United States
Canada
United Kingdom
Australia
European Union
India
Other country/region
Q17
Multiple Choice
What is the highest level of education you have completed?
Less than high school
High school or equivalent
Some college or trade school
Associate degree
Bachelor’s degree
Postgraduate or professional degree
Prefer not to say
Q18
Multiple Choice
What is your current employment status?
Employed full-time
Employed part-time
Self-employed
Unemployed and looking for work
Student
Retired
Unable to work
Caregiver
Prefer not to say
Q19
Chat Message
Welcome! This survey should take only a few minutes. Please answer based on your own experience in the past year. Your responses are confidential.
Q20
Long Text
Any other comments you would like to share about your prior authorization experience?
Max 600 chars
Q21
AI Interview
AI Interview: 2 Follow-up Questions on prior authorization experiences
AI InterviewLength: 2Personality: [Object Object]Mode: Fast
Q22
Chat Message
Thank you for participating! Your feedback will help improve prior authorization processes.
Frequently Asked Questions
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