HEALTH  INSURANCE  UTILIZATION  SURVEY

DO NOT PUT YOUR NAME ON THIS SURVEY!

IT IS FOR STATISTICAL INFORMATION ONLY!

CHECK THE ACCUMULATED LEVEL OF MEDICAL EXPENSES YOU & YOUR DEPENDENTS HAVE INCURRED IN THE LAST 12 MONTHS.

 

YOURSELF

SPOUSE

CHILD

$1,000

     

$2,500

     

$5,000

     

$10,000

     

INDICATE THE APPROXIMATE # OF DAYS SPENT
IN THE HOSPITAL IN THE LAST 12 MONTHS

YOURSELF

SPOUSE

CHILD

INDICATE THE # OF DOCTOR OFFICE VISITS
INCURRED IN THE LAST 12 MONTHS

YOURSELF

SPOUSE

CHILD


 

INDICATE THE # OF EMERGENCY ROOM VISITS
INCURRED IN THE LAST 12 MONTHS

YOURSELF

SPOUSE

CHILD

 

REASONS

 

 

 

INDICATE IF YOU ARE CURRENTLY RECEIVING
TREATMENT FOR ANY OF THE FOLLOWING

 

YOURSELF

SPOUSE

CHILD

CANCER

     

HEART

     

DIABETES

     

BLOOD PRESSURE

     

PREGNANT

     

OTHER

     

PLEASE INDICATE ANY REGULAR PRESCRIPTIONS BEING USED

YOURSELF

 

SPOUSE

 

CHILD

 

ANY ADDITIONAL COMMENTS REGARDING OUR
BENEFIT PROGRAM WOULD BE APPRECIATED

THANK YOU!