2014 Congressional Feedback Form

Share your feedback with us following your meetings with members of Congress. This information is valuable in providing follow-up communication to congressional offices and maximizes our advocacy efforts on behalf of physicians.
1. Please tell us about yourself:
Please tell us about the FIRST office you visited. You will have the opportunity to tell us about your other hill/district visits on subsequent pages.
2. Who did you meet with? (check all that apply)
3. Your relationship with this individual? (check all that apply)
4. Which statement best describes the legislator’s position and sense of urgency for passing H.R. 4015/S. 2000; the legislation that will repeal Medicare’s sustainable growth rate (SGR) formula and establish new payment systems that will support high-quality patient care? (please choose one):
5. Did you ask your legislator specifically how they will show their support for H.R. 4015/S. 2000, and what was their response? (check all that apply):
6. Additional comments about this hill visit or district meeting (please include any AMA follow up needed):
7. Do you have another hill visit or district visit to tell us about?