Third-party premium payments: Take our survey!

1.

Please provide your contact information


*	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	Street 2:
*	City: Required
*	State / Province: Required
*	ZIP Code Required
*	Phone: (ex: 555-555-5555) Required
	Yes, I would like to receive e-mail from American Kidney Fund
	Yes, I would like to receive postal mail from American Kidney Fund
	Keep me logged in. What's this? Remembers your login information for your convenience. Use only on trusted, private computers.

2.

Question - Not Required - Is the above phone number for a cell phone?

3.

Question - Not Required - Can we text you?

4.

Question - Not Required - Name of your dialysis clinic:

5.

Question - Not Required - Name of your insurance:

6.

Question - Not Required - Number of years on your insurance:

7.

Question - Not Required - Number of years on dialysis:

8.

Question - Not Required - Is your plan a Qualified Health Plan through the Marketplace Exchange? Yes
No
I don't know

9.

Question - Not Required - Please check each one of the issues you experienced:

	Reliant on others for transportation.
	Slow process to cash check and get a cashier check/money order.
	Bank/check cashing/money order fees too high.
	Other responsibilities with children/spouse/parent.
	Dialysis related fatigue.
	Not currently employed.
	Lost insurance.
	Worried will lose insurance.
	Lost insurance but was reinstated.
	Do not have a bank account.
	Must buy money orders.
	Need assistance to make appointments/bank visits.
	Do not have a family member or friend who can pay insurance premiums.
	Was unaware your insurance didn't accept direct payments from a charity.

10.

Question - Not Required - Do you have any other medical conditions?

*11.

Question - Required - Would you be willing to file a complaint with insurance regulators?

12.

Question - Not Required - Have you experienced any other problems? If yes, please tell us:

(Maximum response 255 chars, approx. 5 rows of text)

Have you been affected by your health insurer refusing to accept direct AKF HIPP grants? We want to hear from you.