Answers marked with a * are required.
Thank you for getting involved to help raise awareness of Observation Status.
  We need to show CMS that this problem affects thousands of people across the country, so in partnership with the John A. Hartford Foundation, we are collecting stories from the people who have been directly impacted. We hope to get at least a few stories from every state.

If you’ve been impacted by the use of “outpatient” Observation Status directly, or know someone who has, please take a few moments to answer the 11 questions below. We will be in touch if we have any questions.
 
1. Beneficiary Name (the beneficiary is the person who received the services): *
 
 
 
2. Beneficiary State of Residence: *



 
 
 
3. Beneficiary Zip Code: *
 
 
 
4. Your Relationship to the Beneficiary: *






      
 
 
 
5. Your Name (if you are not the beneficiary):
 
 
 
6. Your Email Address: *
 
 
 
7. Your Phone Number: *
 
 
 
8. Number of Days Beneficiary was in Outpatient Observation: *
 
 
 
9. Please summarize your Observation Status story: *
 
 
 
10. Can we share this story (without identifying you unless given express permission) with: *



       		 
 
 
11. Are you willing to speak with the media? (We will provide preparation and support before any interview takes place) *