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 |
|
|
|
|
$2,500 |
|
|
|
|
$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 |
REASON
|
|
|
|
|
|
|
INDICATE IF YOU ARE CURRENTLY RECEIVING
TREATMENT FOR ANY OF THE FOLLOWING
|
|
YOURSELF |
SPOUSE |
CHILD
|
|
CANCER |
|
|
|
|
HEART |
|
|
|
|
DIABETES |
|
|
|
|
BLOOD PRESSURE |
|
|
|
|
PREGNANT |
|
|
|
|
OTHER |
|
|
|
PLEASE INDICATE ANY REGULAR PRESCRIPTIONS
BEING USED
YOURSELF
|
|
|
|
SPOUSE |
|
|
|
CHILD |
|
|
ANY ADDITIONAL COMMENTS REGARDING OUR
BENEFIT PROGRAM WOULD BE APPRECIATED
THANK
YOU!