California High Health Care Bills Survey

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* 1. First Name

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* 2. Last Name

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* 3. Phone number

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* 4. E-mail Address

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* 5. Zip Code

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* 6. What type of health insurance do you have?

Private insurance through Covered California

Private insurance purchased directly from an insurance company

Private insurance purchased through an independent broker

Employer-sponsored insurance

Medi-Cal

Medicare

Uninsured

Other

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* 7. If you have insurance purchased through Covered California, do you receive financial subsidies to help lower your premiums or other costs?

Yes

I don't know

Did not purchase insurance through Covered California

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* 8. Do you have trouble affording any of the following (choose all that apply):

Monthly premium

Deductible

Co-Pays

Co-Insurnace

Prescription drugs

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* 9. Have you ever had an expensive/outrageous health care bill? [From a doctor, hospital, or other health care setting]

Yes

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* 10. Please tell us more about your experience with high health care bills:

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* 11. Are you willing to speak further with Health Access staff about sharing your story?

Yes

Maybe

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* 12. What is the best time to reach you?

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* 13. Are you interested in sharing your story directly with lawmakers through a meeting or phone call?

Yes

Maybe

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* 14. Are you comfortable sharing your story with the media, such as a reporter or local TV station?

Yes

Maybe