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  • Personal Information: The Remainder of The Questions Are About The Primary Payor Health Plan

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    Khan Mohammad Mahmud Hasan
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    This document appears to be a survey for a cardiology clinic collecting personal information about patients such as their age, gender, race, zip code, and health insurance details. It asks the respondent about their relationship to the child patient, how long the child has been in their current health plan, and to rate the child's overall health. The survey is collecting demographic information about patients as well as details about their health insurance coverage.

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    Original Title

    Cardiology 1 c

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    This document appears to be a survey for a cardiology clinic collecting personal information about patients such as their age, gender, race, zip code, and health insurance details. It asks the respondent about their relationship to the child patient, how long the child has been in their current health plan, and to rate the child's overall health. The survey is collecting demographic information about patients as well as details about their health insurance coverage.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    12 views1 page

    Personal Information: The Remainder of The Questions Are About The Primary Payor Health Plan

    Uploaded by

    Khan Mohammad Mahmud Hasan
    This document appears to be a survey for a cardiology clinic collecting personal information about patients such as their age, gender, race, zip code, and health insurance details. It asks the respondent about their relationship to the child patient, how long the child has been in their current health plan, and to rate the child's overall health. The survey is collecting demographic information about patients as well as details about their health insurance coverage.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Cardiology Clinic Survey

    Personal Information
    1.

    Your child's age?

    3.

    Your child's race (Mark all that apply)

    Your
    child
    is:

    00
    11
    22
    33
    44
    55
    66
    77
    88
    99

    Male

    2.

    Female _

    1 American Indian or

    4 Native Hawaiian or

    2 Asian

    5 White

    Alaska Native

    What is the zip code


    where you live?

    00000
    11111
    22222
    33333
    44444
    55555
    66666
    77777
    88888
    99999

    other Pacific Islander

    3 Black/African
    American

    4. What is your age now?


    _ Under 18 _ 18 to 24

    _ 25 to 34

    _ 35-44

    _ 45 to 54

    _ 55 to 64

    _ 65 to 74

    _ 75 or older

    5. Are you
    _ Male

    _ Female

    6. What is the highest grade or level of school you have completed?


    _ 8th grade or less _ Some high
    school

    _ High school

    _ Some college or _ 4-year college

    _ More than 4-year

    _ Aunt or uncle

    _ Older brother or _ Other relative

    _ Legal guardian

    or GED

    2-year degree

    college degree

    7. How are you related to the child?


    _ Parent

    _ Grandparent

    sister

    8. In general, how would you rate your child's overall health now?
    1 Excellent

    2 Very Good

    3 Good

    4 Fair

    5 Poor

    The remainder of the questions are about the primary payor health plan.
    9. Please select the plan that is paying for this visit.
    _ Blue Cross/Blue Shield _ Care America

    _ Kaiser Permanente

    _ Maxicare

    _ Trustmark

    10. How many months or years in a row has your child been in this health plan?
    _ Less than 12 months

    _ 12 up to 24 months

    _ 2 up to 5 years

    _ 5 up to 10 years

    _ 10 or more years

    11. Which of the following best describes this health insurance plan?
    _ Your child can go to almost any doctor/hosptial. The amount the insurance pays does not depend on which doctor or hosptial your child uses.
    _ Your child can go to almost any doctor/hospital. Your insurance pays a lower amount if you use doctors/hospitals that are not on an approved list.
    _ Your health insurance plan pays only if you go to doctors/hospitals on the plan's approved list OR if you get a referral.

    12. Did you have to get permission from your plan before you could come to the clinic today?
    _ Yes

    _ No

    Please turn over to


    complete this survey

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