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* 1. Which of your service lines have been impacted by Change Healthcare cyberattack? (check all that apply)

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* 2. What state(s) do you have organization(s) in?

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* 3. What steps have you taken to date to combat the impact of the Change Healthcare outage? (check all that apply)

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* 4. What sources of funding have you applied for during the Change Healthcare outage, and what is the status of those applications?

  Status of Application
UHG Temporary Funding Assistance Program
Medicare Administrative Contractor (MAC)
State Medicaid Agency
Other managed care plans (please specify below)

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* 5. If you received funding, was the amount received sufficient to cover your immediate cash flow concerns?

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* 6. Approximately how many days Cash on Hand does your organization have?

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* 7. Please tell us what other help you need to address the impact of the Change Healthcare payment platform outage on your organization(s).

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* 8. Please share your contact information below.

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