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NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.

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* 1. Do you currently have health insurance, or not?

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* 2. Were you without health insurance for any amount of time in the past 12 months, or not?

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* 3. Who pays for your health insurance? (Check all that apply)

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* 4. Which of the following services are covered, in total or in part, by your health insurance plan(s)? (Check all that apply)

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* 5. Why do you currently not have health insurance? (Check all that apply)

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