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:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
3.
Beneficiary Zip Code:
*
4.
Your Relationship to the Beneficiary:
*
Self
Spouse
Child
Parent
Other Relative
Non-Relative Caregiver
Attorney or Other Advocate
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:
*
Media
Legislators
Other Advocates or Advocacy Groups
None, thank you
11.
Are you willing to speak with the media? (We will provide preparation and support before any interview takes place)
*
Yes
No