1.

Do you have health insurance through your employer (or through the employer of a spouse, parent, or member of your household)?

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* 1. Do you have health insurance through your employer (or through the employer of a spouse, parent, or member of your household)?

The policy holder’s place of work has:

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* 2. The policy holder’s place of work has:

Your health insurance coverage can best be described as:

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* 3. Your health insurance coverage can best be described as:

In the last ten years, have you (or another person covered under the same insurance policy) had a healthcare condition requiring rehabilitative or habilitative services (Physical Therapy, Occupational Therapy, Speech Therapy, etc) and/or devices (durable medical equipment , orthotics, prosthetics or other assistive device)?

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* 4. In the last ten years, have you (or another person covered under the same insurance policy) had a healthcare condition requiring rehabilitative or habilitative services (Physical Therapy, Occupational Therapy, Speech Therapy, etc) and/or devices (durable medical equipment , orthotics, prosthetics or other assistive device)?

Rehabilitative or habilitative services you (or another person covered under your insurance) have required include (choose all that apply):

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* 5. Rehabilitative or habilitative services you (or another person covered under your insurance) have required include (choose all that apply):

The assistive device(s) you use the most in your daily living is:

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* 6. The assistive device(s) you use the most in your daily living is:

You generally find your insurance coverage:

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* 7. You generally find your insurance coverage:

Are there limits, restrictions or caps in your insurance coverage that prevent you from getting your rehabilitation needs met? (For example, a limit on the number of sessions per year, or dollar limits on services or policies that require referrals before going to a specialist.)

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* 8. Are there limits, restrictions or caps in your insurance coverage that prevent you from getting your rehabilitation needs met? (For example, a limit on the number of sessions per year, or dollar limits on services or policies that require referrals before going to a specialist.)

Please estimate how much you spend out of pocket each year for medical supplies and devices:

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* 9. Please estimate how much you spend out of pocket each year for medical supplies and devices:

Please provide below any additional significant information about your experience with employer-sponsored health insurance coverage for disability-related healthcare services. Give us your contact info if you would like a copy of the results.

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* 10. Please provide below any additional significant information about your experience with employer-sponsored health insurance coverage for disability-related healthcare services. Give us your contact info if you would like a copy of the results.

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