COPD Satisfaction Survey Page 1 Question Title Complete this short survey by January 15, 2010, and you will be entered into a drawing for a $50 Walmart gift card! Question Title * The following fields are optional. We will need your name, ID# and phone number, however, if you wish to be entered into a drawing for a $50 Walmart gift card. **Disclosing your e-mail address is optional. By providing your e-mail address on this form, you are authorizing BlueChoice® HealthPlan to send you information related to health and disease management programs via e-mail. Name: BlueChoice HealthPlan ID#: Phone Number with Area Code: E-mail Address: BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. Next