Surprise Medical Bill Story
First Name
Last Name
Email Address
Phone Number
City
State
Date of Birth
MM
/
DD
/
YYYY
Age
Race/Ethnicity
How did you get your insurance? E.g. Employer sponsored, Marketplace, Medicare, Medicaid, etc.
What is your work status? E.g. Retired, Full-Time, Part-Time, Unemployed, Student.
For what were you seeking treatment when you incurred a surprise, out of network bill?
Did your surprise, out of network bill include any emergency services? If so, please describe them.
Your full story.
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