Name:

Organization(If applicable):

E-mail address:

Address:

City: State: Zip:

Phone:

Fax:

Regarding your story, were you:

• The patient
  Family member of the patient
  Friend of the patient
  Health care provider/worker
  Co-worker

Date(s) problem(s) occurred (Approximately):

What kind of health care coverage do you have?:

• HMO
  PPO: Preferred provider organizations
  Medicare/Medicaid
  Other (Please specify)
  

Under your managed care insurance plan, were you aware of any complaint procedure/appeals process? YES NO

Did you file a complaint/appeal with your managed care plan?: YES NO

If yes, what was the result?:

Were you satisfied with the outcome of your complaint/appeal?: YES NO

Did you change managed care plans? YES NO

Who has been helpful (if anyone) in your situation?: (Check all that apply)

• Doctor
  Nurses
  Hospital Staff
  Managed care plan
  State Ombudsman
  Other (Please specify)
  

What kind of quality issue does your story fall under?: (Check all that apply)

• Refusal to provide covered services (Check which ones)
  
  • Tests
    
  • X-rays
    
  • Emergency room
  • Out of area services
  • Medications
  • Medical_Treatments
  • Preventive_Services
  • Hospitalization

  Refusal to refer patient to a specialty physician
  Denial of choice of doctor and/or hospital
  Discharge from the hospital too soon
  Delay in providing necessary treatment
  Delay in getting a doctor's appointment
  Clinics and services are located in inconvenient areas
  Failure to diagnose and/or misdiagnosis of illness
  Incompetent medical treatment of diagnosed illness
  Insensitive/inhumane caring and treatment of patient
  Poor communication with patient regarding reason for treatment, treatment alternatives and probable treatment outcomes
  Failure to cover the costs of medical services
  Other Please Specify:
  

Please describe your story in as much detail as possible

May we use your name in connection with your story? YES NO

May we call you to talk about your story? YES NO

In the future, would you be willing to speak with a reporter? YES NO

Would you like us to send you a list of groups that work on health care issues in your state? YES NO

Would you like to be put on our mailing list? YES NO