The California Breastfeeding Coalition is interested in your feedback on your experience with insurance reimbursement for Breastfeeding Support, Services, and Supplies. This information will be shared with our partners to advocate for improved reimbursement of breastfeeding services in California.

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* 1. Please check one to identify yourself.

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* 2. Type of insurance plan billed:

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* 3. Name of Insurance Plan:

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* 4. Were you seeking or billing for: (Check all that apply).

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* 5. What was the date of service (approximately)?

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* 6. At the time of service, the mother was:

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* 7. Was your insurance claim denied, delayed or paid? (Check all that apply).

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* 8. What reason(s) was/were given for help or supplies not being covered/paid for?

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* 9. What other problems did you experience in providing or receiving Breastfeeding Support, Services and Supplies?

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* 10. What other successes did you experience in providing or receiving Breastfeeding Support, Services and Supplies?

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* 11. May we contact you for further information or to clarify?

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* 12. Contact Information:

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