An aco patient attribution survey form helps healthcare organizations understand whether patients know they are part of an accountable care arrangement and whether the primary care provider on record matches the doctor they actually consider their main provider. This template is built to capture that information clearly, with straightforward questions about patient identity, provider recognition, and recent primary care visits.
The survey also supports practical attribution review by collecting details such as date of birth, member or patient ID, contact information, assigned PCP awareness, and whether the listed provider is the patient's main doctor. It includes space to capture the provider name patients recognize and a rating question focused on communication quality, which gives teams both operational data and patient experience feedback in one form.
This makes the template useful for outreach, attribution validation, quality improvement, and care coordination follow-up. Teams can use responses to spot mismatches in provider assignment, identify patients who are unsure about their PCP relationship, and improve communication around membership, access, and ongoing primary care engagement.
