First Name

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* 1. First Name

Last Name

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* 2. Last Name

Phone number

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* 3. Phone number

E-mail Address

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* 4. E-mail Address

Zip Code

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* 5. Zip Code

What type of health insurance do you have?

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

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

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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?

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

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

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

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

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

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

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

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

What is the best time to reach you?

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

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

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

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

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

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