Exit this survey 2015 Congressional Feedback Form Share your feedback with us following your meetings with members of Congress. This information is valuable in providing follow-up communication to congressional offices and maximizes our advocacy efforts on behalf of physicians. Question Title * 1. Please tell us about yourself: Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Email Address: Phone Number: Please tell us about the FIRST office you visited. You will have the opportunity to tell us about your other hill/district visits on subsequent pages. Question Title * 2. Who did you meet with? (check all that apply) Senator/Representative Staff member(s) Name of person(s) you meet with Question Title * 3. Your relationship with this individual? (check all that apply) First time visiting Constituent Personal friend or relative Financial donor Acquaintance Campaign adviser or volunteer Other (please specify) Question Title * 4. Did you ask your legislator to make this the year SGR is repealed once and for all and replaced with reform-minded legislation that promotes new delivery and payment models? What was their response? Yes No Comments: Question Title * 5. What statement best describes the legislator’s posture on SGR and the realistic prospects for repeal in this Congress? (Please choose one) Senses a lack of focus by Congressional leaders on SGR repeal to this point and believes that another patch of 12 months or longer is likely before the March 31 deadline. Feels that serious work is being done to repeal SGR, but a short-term patch of a few months duration in advance of the March 31 deadline is still likely to provide additional time to work out the details of permanent repeal before the end of the year. Believes there is a real urgency on the part of leadership in Congress to finally repeal the SGR and enact payment and delivery reform, predicts this can still be done in advance of the March 31 deadline. Comments: Question Title * 6. How does your member of Congress feel about budget offsets (aka “pay fors”) in relation to the SGR? Insists that the entire cost of SGR repeal must be paid for. Believes the problem has gotten so out of control that a partial pay for would be sufficient, if other meaningful policies changes are included in the bill. Does not believe a pay for is required. Comments: Question Title * 7. Is your legislator willing to take additional action to raise awareness for repealing the SGR on social media and use their official Twitter account to tweet a pro-repeal message that will use the #FIXMEDICARENOW hashtag? (Please make sure to emphasize this request.) Yes No Comments: Question Title * 8. If you had the opportunity to discuss the regulatory tsunami facing physicians, was your legislator receptive to easing regulatory burdens by providing greater stability and flexibility in the Meaningful Use, Physician Quality Reporting System, and Value-based Payment Modifier programs? Yes No Comments: Question Title * 9. Did your member of Congress or their staff agree to cosponsor the Independent Payment Advisory Board repeal legislation, S. 141 Protecting Seniors’ Access to Medicare Act of 2015? Yes No Comments: Question Title * 10. Additional comments about this hill visit or district meeting (please include any AMA follow up needed): Question Title * 11. Do you have another hill visit or district visit to tell us about? Yes No Next