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* 1. The % of my patients who don't take their meds because of cost is likely:

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* 2. My patients are reminded to notify me if they can't afford their meds.

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* 3. My community practice, FQHC, or hospital-based clinic helps my patients obtain affordable meds.

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* 4. The unffordability of meds has contributed to the hospitalization of at least one of my patients.

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* 6. This hospital's discharge instructions include information about obtaining unaffordable meds.

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* 7. This hospital has a prescription assistance/medication access program to which I can refer patients who can't afford their meds.

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* 8. I refer the following number of patients to this hospital's prescription assistance/medication access program monthly:

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* 9. This hospital's prescription assistance/medication access program provides regular reports of the number of my patients it has helped and the number and dollar value of meds it has obtained for them.

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* 10. About my practice:

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* 11. About my credentials:

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* 13. Here are my questions or comments:

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* 14. I want more information about accessing unaffordable medicines.

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