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Member Survey
Member Name:
*
Member Number:
*
Address:
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City:
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State:
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Zip:
*
1. Do you understand what providers are available to you?:
Yes
No
If no, please explain:
2. Do you need assistance with choosing or changing your Primary Care Physician?:
Yes
No
If yes, provide comments regarding assistance needed.
If yes, please explain:
3. Do you understand your plans urgent or emergency care benefit?:
Yes
No
If no, please explain:
4. Do you have questions about copayments, deductibles or coinsurance?:
Yes
No
If yes, please explain:
5. Do you have any cultural or linguistic needs that we may address?:
Yes
No
If yes, please explain:
6. Do you have any questions or special needs that have not been addressed in this survey?:
Yes
No
If yes, please explain:
7. Are you aware of your appeal rights regarding claims and referral decisions?:
Yes
No
If yes, please explain:
8. Do you understand your plans out of area coverage?:
Yes
No
If no, please explain:
9. Did you receive your enrollment packet that includes Member ID Card, Summary of Benefits and Member Handbook?:
Yes
No
Are there any items missing from your enrollment Packet? Please note any missing items:
10. Do you have any questions about your pharmacy co-pay's?:
Yes
No
If yes, please explain:
11. Do you or your family have any special health needs?:
Yes
No
12. Why did you choose Lovelace Health Plan as your health plan provider?:
Cost
Reputation
Employee Offering
Other
