Form 1 Patient Survey

Patient Survey

D ate:

Interviewer:

Location:

Interview completed?

□ Yes □ No □ Refused

P

OMB#:0925-0458 EXP. DATE: 12/31/2013

atient Information

City, State:

Country: ­

Information obtained from:

□ Patient □ Spouse/Partner □ Parent/Guardian □ Other

1. How were you (the patient) referred for treatment to NIH?

□ Primary care physician □ Specialty physician □ Internet □ Patient refused to answer

□ Other source (specify):

2. Did you (the patient) provide a copy of your medical record to your doctor at NIH?

□ Yes □ No □ Unsure □ Patient refused to answer □Patient's referring MD provided medical record

3. When you (the patient) go to a medical provider for medical care outside of NIH, do you:

□ Only go to the doctor or hospital/clinic specified by your insurance

□ Choose a doctor or hospital/clinic only from a list provided by your insurance

□ Select any doctor and share the cost for out of network service

□ Select any doctor or hospital/clinic and pay out of your own pocket

□ Not Applicable

□ Unsure

□ Patient refused to answer

4. Do you (the patient) have health insurance?

□ Yes □ No □ Unsure □ Patient refused to answer

1. Do you (the patient) have health insurance coverage for the condition for which NIH is seeing you (the patient) today?

□ Yes □ No □ Unsure □ N/A □ Patient refused to answer

2. What is your (the patient’s) primary health insurance company?

□ Commercial (circle: HMO / PPO / other) □ Medicare □ Medicaid □ Other Government

□ Non-USA □ Unsure □ Patient refused to answer

Specify:

3. If your (the patient’s) primary insurance does not cover all costs, is there coverage from a second insurance source?

□ None □ Commercial (circle: HMO / PPO / other) □ Medicare □ Medicaid

□ Other Government □ Non-USA □ Unsure □ Patient refused to answer

Specify:

4. Are you (the patient) presently near to or exceeding the annual or lifetime insurance limits for the condition for which you were referred to NIH?

□ Yes □ No □ Unsure □ N/A □ Patient refused to answer

Public reporting burden for this collection of information is estimated to average 6 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0458). Do not return the completed form to this address.

5. Have you (the patient) been denied or changed health insurance because of the condition for which you were referred to NIH?

□ Yes, patient denied further coverage by insurance company

□ Yes, patient chose different benefits with another company

□ Yes, patient changed employment or employment status

□ No

□ Unsure

□ Patient refused to answer

6. If health reforms are implemented and annual / lifetime limits no longer apply, would you (the patient) continue to participate in research at NIH if they were to bill your insurance?

□ Yes □ No □ Unsure □ N/A □ Patient refused to answer

7. Would you (the patient) be willing to provide your insurance to NIH even if it required you to pay out of pocket expenses toward your co-pay or deductible?

□ Yes □ No □ Unsure □ Patient refused to answer

8. Under your current coverage, if NIH were to bill your (the patient’s) insurance for its services, would you:

□ Continue to participate in research at NIH, because:

□ I am interested in participating in a research protocol

□ I think that NIH provides the best care for my condition

□ The cost of clinical care outweighs any insurance concerns

□ Unsure

□ Other:

□ No longer participate in research at NIH, because:

□ I think it is not appropriate to bill a research participant for care

□ I cannot afford the cost of care, including co-pays and deductibles

□ I would exceed annual / lifetime limits

□ I fear losing my insurance

□ Unsure

□ Other:

□ Patient refused to answer