Disclaimer Agreement – Comment or Suggestion Form

TriValley Primary Care is providing the means for you to provide your comments and suggestions via this on-line link. This is intended to be an easy means to do this. So that this may be a good experience for all concerned, there are rules to follow. To proceed further, you must agree to the following rules:

• I agree to read the instructions on the comment form. In particular, I will carefully review the purpose and limitations statements on the form.

• I understand and agree that the comment form is NOT to be used as a means of dialog (two-way contact) with a TriValley physician or office, but rather to convey my thoughts on how the practice may be improved or recite my experience with TriValley staff, a provider, policy, or process. If I need to speak with a physician or nurse, I will call the office.

• I understand that this link is NOT to be used to ask a question. I will direct my questions to the medical office I visit or the TriValley Corporate office by means of telephone or U.S. postal service mail or in person as appropriate.

• I agree that I will NOT use this form to request services of any kind, but especially those that need immediate attention or where my health may be jeopardized by a delay.

• I understand that should I make a suggestion, I do so with no expectation of compensation or other remuneration, or for special treatment of any kind. I acknowledge that no compensation or special treatment will be forthcoming. Furthermore, I understand that TriValley has no obligation to give my suggestion any more than cursory consideration.

• I understand that my comment or suggestion may not be acknowledged. If I desire a response, I will call the office. If it is an urgent matter or an emergency, I agree to seek care at the most immediately available medical facility, including a hospital emergency room or I shall call 911, as appropriate.

• Special Notice: I understand that this form may NOT be used to make an allegation of serious wrong-doing (criminal or civil) by a TriValley provider or staff member. However, I may use this link (Contact Risk Manager) to file a report regarding an alleged serious or illegal action or criminal activity.

Having read and understanding all of the above, I agree to use the form for the stated purposes as shown on the form. By clicking the “I Agree” button, below, I affirm my intention to abide by the above rules.