Survey

We want to hear your personal experience with health care and insurance. Your story will help us document what’s happening to thousands of people.

	1.My experience is mostly about: (Your experience may touch on several topics, but please pick a main category):*
	A doctor or doctors A hospital Insurance coverage that I bought myself Medicaid Medicare Part D My employer ’s coverage A drug
	2.Tell your story here.
	3.Would you let us publish your comments (we will not publish without contacting you again to confirm your identify). *
	Yes No
	4.Please provide your phone number and email address so we can communicate with you and learn more about your experience.
	First Name:* Last Name:* Email:* Street 1:* Street 2: City:* AlaskaAlabamaArizonaArkansasCaliforniaColoradoConnecticutD.C.DelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming* Zip:* Phone Number:
	5.Yes, I would like to receive free periodic updates from The Philadelphia Inquirer’s web page, Living Dangerously; Casualties in the Health Insurance Crisis. (Sí, me gustaría recibir boletines con información del consumidor de Philadelphia Inquirer’s web page.) *
	Yes No

* = Required Fields