Surprise Medical Bill Story
First Name
Your answer
Last Name
Your answer
Email Address
Your answer
Phone Number
Your answer
City
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State
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
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?
Your answer
Did your surprise, out of network bill include any emergency services? If so, please describe them.
Your answer
Your full story.
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