Port Division Healthcare Survey

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company
Cell Phone Number
Date
MM slash DD slash YYYY
Do you currently have health insurance?
If yes, What is the health insurance provider name?
If No, what is the reason?
How many years have you been uninsured?
Only numbers
Have you ever had to seek medical care outside of the US, due to high costs and/or lack of insurance?
Have you ever been denied health insurance due to your income? (too high for ACA subsidies, MediCal, etc.)
Have you ever postponed medical treatment due to lack of/or inadequate health insurance?
Does your immediate family have health care? If so, who provides it?
Have you ever been diagnosed with a condition that was more advance due to delayed treatment?
Are you an Eligible Employee/Independent Contractor?