SUBMIT YOUR MEDICARE "IMPROVEMENT STANDARD" STORY
Answers marked with a * are required.
1.
Beneficiary and Contact Information
Please be sure you have completed this section accurately, as we may not be able to contact you if you do not.
1.
If
not
the beneficiary in question, first name of person completing this form (if you ARE the beneficiary, skip to question #6):
2.
Last name of person completing this form:
3.
Phone number of person completing this form:
4.
Email address of person completing this form:
5.
Address of person completing this form:
Street
Town/City
State
Zip
6.
Beneficiary's relationship to person filling out this form:
*
Self
Parent
Child
Client
Patient
Other (Please Specify)
7.
First name of beneficiary:
*
8.
Last name of beneficiary:
*
9.
Phone number of beneficiary:
*
10.
Email address of beneficiary:
11.
Address of beneficiary:
*
Street
Town/City
State
Zip
12.
Check all that apply. Can we share this story,
without identifying you
, with:
*
Other Advocates
Media
Government Contacts/Decision Makers
Scholars
Policy Makers
No, thank you
13.
would you be willing to speak directly about the problem to any of the following:
*
Other Advocates
Media
Government Contacts/Decision Makers
Scholars
Policy Makers
No, thank you
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