Client Information

1) Name:

2) Address: 3) City: 4) State: 5) Zip:  

6) Home phone: 7) Cell phone: 8) Other phone:

9) Email:

10) Best times to contact:

11) Household size: 12) Marital status:

13) Date of birth: 14) Ethnicity: 15) Gender: Male Female

16) Profession/employer:

17) Family income: per Week Month Year

18) Type and name of health insurance (when debt incurred):

19) How did you learn about The Access Project:

Primary Contat Information (if you are contacting us on behalf of somebody else)

1) Primary contact name: 2) Relationship to debtor:

3) Address: 4) City: 5) State: 6) Zip:  

7) Home phone: 8) Cell phone: 9) Other phone:

10) Email:

11) Best times to contact:

Story Details

1) Briefly describe the medical situation that made you seek care?
 

2) Please list any hospitals, doctors, ambulance companies or other medical providers to whom you owe money.

a) $

b) $

c) $

d) $

e) $

f) $

3) What consequences have you faced due to your medical debt?

4) Have you taken any steps to deal with these medical bills?

5) Have you recently applied to any public programs?

If you are privately insured:

1) What are the characteristics of your health insurance plan (deductible, co-payments, insurance caps, etc.)?

If you are publicly insured through Medicaid, Medicare, or another program:

1) Name of program and characteristics of program.