Skip to content

Healthcare Expenses Template

NOTE: If the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) applies to you and your intended use of SurveyMonkey, this template is NOT intended for your use without 1) a SurveyMonkey ‘HIPAA-enabled’ account, and 2) a business associate agreement with us, which can be purchased by contacting our sales team. Please see our Acceptable Uses Policy for more information.
1.Do you currently have health insurance, or not?
2.Who pays for your health insurance? (Check all that apply)
3.How much money, in U.S. dollars, do you spend on health insurance premiums, deductibles, copays, and co-insurance fees in a typical month?
4.How much money, in U.S. dollars, do you spend on healthcare in a typical month? (Count all healthcare-related costs, including health insurance premiums, deductibles, copays, co-insurance fees, and any other out-of-pocket expenses for medical, dental, or vision services and medications.)
5.In the last 12 months, has a lack of money kept you from going to the doctor, or not?
Current Progress,
0 of 5 answered