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MEDICAL NEEDS ANALYSIS
1.
Male or Female?
M
F
2.
Age?
3.
Do you know how much you would pay if you were hospitalized tomorrow?
Yes
No
4.
Does your current plan cover Ambulance transportation
Yes
No
5.
Would a $2,000+ hospital bill create financial stress?
Yes
No
6.
Do you understand what your health plan covers for home health care?
Yes
No
7.
Do you fill your prescriptions monthly or quarterly?
Monthly
Quarterly
8.
Do you feel like your current plan is affordable?
Yes
No
9.
Are all of the providers and hospitals you regularly see in your current network?
Yes
No
10.
Has your financial situation changed in the past year?
Yes
No
11.
Has your medical condition changed in the past year?
Yes
No
12.
Do you have a savings account to cover an unexpected event that would require a long hospital stay or long-term care? [Average 5-day hospital stay is $10,000 and does not include major procedures, ambulance fees, or other charges]
Yes
No
13.
Do you have a savings account to help cover the cost of your child's tuition? [Average cost of tuition and fees vary; 2018-2019 average annual tuition was $35,676 at private colleges, $9,716 for state residents at public colleges, and $21,629 for out-of-state students at state school- source, US News]
Yes
No
14.
Do you have a savings account to help cover the cost of a root canal? [Average cost = $700-$1,400]
Yes
No
15.
Do you have any expected medical procedures?
Yes
No
16.
do you have any additional services required? [chiropractic care, mental health, physical therapy, ect?]
Yes
No
17.
Do you or anyone in your family have risk of cancer? [Average cost of cancer treatment: one round of chemotherapy averages around $60,000 for an eight-week period, other medications average $10,000 per month]
Yes
No
18.
Do you live part-time in another state or travel frequently?
Yes
No
19.
Do you currently receive health coverage through a former employer or organization?
Yes
No
20.
What company do you currently have health insurance with?
21.
Best phone number to text/call [MUST BE A VALID PHONE NUMBER]
22.
Best email [MUST BE A VALID EMAIL]
23.
Who referred you?
