GROUP HEALTH INSURANCE SURVEY

Do you have a moment to take a brief survey? MSSNY is exploring the possibility of developing a cost-effective health plan for our members, their dependents, and their employees (not an association health plan [AHP]).

Our ability to move forward will be based on the number of members that express an interest in participating with this new group.

Last Name

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* 1. Last Name

First Name

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* 2. First Name

Age

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* 3. Age

Gender

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* 4. Gender

Zip code

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* 5. Zip code

How many dependents would you need to cover?

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* 6. How many dependents would you need to cover?

Do you have employees within your practice?

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* 7. Do you have employees within your practice?

If yes, do you want to cover your employees?

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* 8. If yes, do you want to cover your employees?

Current type of coverage

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* 9. Current type of coverage

Please add any comments below

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* 10. Please add any comments below

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