* 1. First Name

* 2. Last Name

* 3. Phone number

* 4. E-mail Address

* 5. Zip Code

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

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

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

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

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

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

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

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

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

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