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