Medical Debt Survey

*
1. In which State do you live?

In which State do you live? State:
ZIP/Postal Code:
Gender (M or F):

*
2. Is Medical Debt the reason you are considering bankruptcy or is Medical Debt the primary reason you are having financial difficulties?

Is Medical Debt the reason you are considering bankruptcy or is Medical Debt the primary reason you are having financial difficulties? Medical Debt is the primary reason for my financial difficulties

Medical Debt is not the main reason, but is a large contributor

My financial difficulties are primarily due to employment

Other (please specify)

*
3. How much Medical Debt did/do you have?

How much Medical Debt did/do you have? $0.00 to $4,999.99

$5,000.00 to $14,999.00

$15,000.00 or more

Other (please specify)

4. With regard to insurance please select the following (in the comments please type the name of your insurer and any other information about your insurer):

	Less than $500 deductible	Between $500 and $1499 deductible	Between $1500 and $3500 deductible	Greater than $3500 deductible
Individual Plan	*With regard to insurance please select the following (in the comments please type the name of your insurer and any other information about your insurer): Individual Plan Less than $500 deductible	Individual Plan Between $500 and $1499 deductible	Individual Plan Between $1500 and $3500 deductible	Individual Plan Greater than $3500 deductible
Individual Family Plan	Individual Family Plan Less than $500 deductible	Individual Family Plan Between $500 and $1499 deductible	Individual Family Plan Between $1500 and $3500 deductible	Individual Family Plan Greater than $3500 deductible
Small Employer Plan	Small Employer Plan Less than $500 deductible	Small Employer Plan Between $500 and $1499 deductible	Small Employer Plan Between $1500 and $3500 deductible	Small Employer Plan Greater than $3500 deductible
Large Employer Plan	Large Employer Plan Less than $500 deductible	Large Employer Plan Between $500 and $1499 deductible	Large Employer Plan Between $1500 and $3500 deductible	Large Employer Plan Greater than $3500 deductible
Medicaid	Medicaid Less than $500 deductible	Medicaid Between $500 and $1499 deductible	Medicaid Between $1500 and $3500 deductible	Medicaid Greater than $3500 deductible
Kids Plan	Kids Plan Less than $500 deductible	Kids Plan Between $500 and $1499 deductible	Kids Plan Between $1500 and $3500 deductible	Kids Plan Greater than $3500 deductible
No Insurance	No Insurance Less than $500 deductible	No Insurance Between $500 and $1499 deductible	No Insurance Between $1500 and $3500 deductible	No Insurance Greater than $3500 deductible

Other (please specify)

5. What do you consider to be an outrageous deductible?

What do you consider to be an outrageous deductible? $500

$1000

$3000 for a family

All are outrageous

Other (please specify)

6. Culturally speaking, bankruptcy carries many connotations. Which of these statements most closely describe your view of bankruptcy?

Culturally speaking, bankruptcy carries many connotations. Which of these statements most closely describe your view of bankruptcy? Bankruptcy is for those that are not smart enough to manage their finances

Bankruptcy is generally looked down on by my friends and family

Bankruptcy is a legitimate means to help an individual start again

Bankruptcy is embrassing

Bankruptcy is a protection for consumers

Bankruptcy is used by people to cheat the system

Other (please specify)

7. With regard to your health, select the responses that most closely explain your feelings about how much control you have over your health status:

With regard to your health, select the responses that most closely explain your feelings about how much control you have over your health status: I am completely responsible for my health regardless of external factors

While I am responsible for exercise and eating there are factors beyond my control

I own a vehicle

I have access to grocery stores with fresh fruits and vegetables

I rent or own a house

I am responsible for eating healthy

There are genetic factors with regard to health that I cannot control

I live in a clean environment free from pollution

I have health insurance

I graduated from high school

I am seeking a bachelors degree or have graduated with one

I seek out preventive care and screenings every year

Other (please specify)

8. If you are considering bankruptcy, which of the following have you done?

If you are considering bankruptcy, which of the following have you done? I have talked with the Financial Assistance Group at the hospital/clinic or organization that provided me medical services

I have been granted a partial forgiveness on my medical bills by a hospital, provider or insurance company

I use my personal credit cards to pay my medical debt

I have renegotiated my medical bills payment terms

I have talked with Legal Services to understand Chapter 7, Chapter 13 and Chapter 20 bankruptcy options

Bankruptcy it too expensive for me

I have sought assistance for my medications from a Patient Assistance Program

Other (please specify)

9. Please share any other information you feel is pertinant to this topic:

Please share any other information you feel is pertinant to this topic:

Medical Debt Survey
Exit this survey

1. Default Section

*
1. In which State do you live?

*
2. Is Medical Debt the reason you are considering bankruptcy or is Medical Debt the primary reason you are having financial difficulties?

*
3. How much Medical Debt did/do you have?

4. With regard to insurance please select the following (in the comments please type the name of your insurer and any other information about your insurer):

5. What do you consider to be an outrageous deductible?

6. Culturally speaking, bankruptcy carries many connotations. Which of these statements most closely describe your view of bankruptcy?

7. With regard to your health, select the responses that most closely explain your feelings about how much control you have over your health status:

8. If you are considering bankruptcy, which of the following have you done?

9. Please share any other information you feel is pertinant to this topic:

Medical Debt SurveyExit this survey

1. Default Section

*1. In which State do you live?

*2. Is Medical Debt the reason you are considering bankruptcy or is Medical Debt the primary reason you are having financial difficulties?

*3. How much Medical Debt did/do you have?

4. With regard to insurance please select the following (in the comments please type the name of your insurer and any other information about your insurer):

5. What do you consider to be an outrageous deductible?

6. Culturally speaking, bankruptcy carries many connotations. Which of these statements most closely describe your view of bankruptcy?

7. With regard to your health, select the responses that most closely explain your feelings about how much control you have over your health status:

8. If you are considering bankruptcy, which of the following have you done?

9. Please share any other information you feel is pertinant to this topic:

Medical Debt Survey
Exit this survey

*
1. In which State do you live?

*
2. Is Medical Debt the reason you are considering bankruptcy or is Medical Debt the primary reason you are having financial difficulties?

*
3. How much Medical Debt did/do you have?