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Prior Authorization Delays Patient Survey Template

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

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?
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?
Q10
ranking
Rank the most frustrating parts of prior authorization from most to least frustrating.
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.
Q14
dropdown
What is your age?
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?
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 Interview
Q22
chat message
Thank you for participating! Your feedback will help improve prior authorization processes.

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Prior Authorization Delays Patient Survey Template - Survey Template | QuestionPunk