DO NOT PUT YOUR NAME ON THIS SURVEY!
IT IS FOR STATISTICAL INFORMATION ONLY!
CHECK THE ACCUMULATED LEVEL OF MEDICAL EXPENSES YOU & YOUR DEPENDENTS HAVE INCURRED IN THE LAST 12 MONTHS.
|
YOURSELF |
SPOUSE |
CHILD |
|
|
$1,000 |
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|
$2,500 |
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|
$5,000 |
|||
|
$10,000 |
INDICATE THE APPROXIMATE # OF DAYS SPENT
IN THE HOSPITAL IN THE LAST 12 MONTHS
|
YOURSELF |
|
SPOUSE |
|
CHILD |
INDICATE THE # OF DOCTOR OFFICE VISITS
INCURRED IN THE LAST 12 MONTHS
|
YOURSELF |
|
SPOUSE |
|
CHILD |
INDICATE THE # OF EMERGENCY ROOM VISITS
INCURRED IN THE LAST 12 MONTHS
|
YOURSELF |
|
SPOUSE |
|
CHILD |
REASONS |
|
|
|
|
|
|
INDICATE IF YOU ARE CURRENTLY RECEIVING
TREATMENT FOR ANY OF THE FOLLOWING
|
YOURSELF |
SPOUSE |
CHILD |
|
|
CANCER |
|||
|
HEART |
|||
|
DIABETES |
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|
BLOOD PRESSURE |
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|
PREGNANT |
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|
OTHER |
PLEASE INDICATE ANY REGULAR PRESCRIPTIONS BEING USED
|
YOURSELF |
|
|
|
SPOUSE |
|
|
|
CHILD |
|
|
ANY ADDITIONAL COMMENTS REGARDING OUR
BENEFIT PROGRAM WOULD BE APPRECIATED
THANK YOU!