2012 Patient Survey

 Purpose:  During the past several years, "Hemophilia Patient and Program Support, Inc.," a non-profit corporation established by the Delaware Valley Chapter, has contributed over $800,000.00 in support of patient and program needs in our region.  Please help us continue this support by completing the survey below and returning it to us in the envelope provided.  Your opinions are very important to us and to your home care companies.  Thank you for completing the survey.

 
 
1.

Are you satisfied with the services provided by your homecare company (the company that delivers your clotting factor)?

 If not, please describe any problem with the services provided by your home care company.
Yes
No
  • Comment:

  • 500 characters left.
2.

If you are willing to disclose it, please state the name of your home care company.
 

50 characters left.
3.

Does your health insurance company provide satisfactory coverage for your bleeding disorder?

If not, please describe the problems you encounter, if any, with insurance coverage for -  
Yes
No, there is a problem with clotting factor;
No, there is a problem with home nursing care;
No, there is a problem with access to a hemophilia treatment center; and/or
No, there is a problem with blood studies at the coagulation lab associated with your treatment center.
4.

Does your health insurance company allow you to obtain clotting factor from one of the five HPPS companies (which are listed below)?

 

Accredo's Hemophilia Health Services;
Coram Hemophilia Services;
CVS/Caremark Specialty Pharmacy;
National Cornerstone HealthCare Services; and
Walgreens-OptionCare Hemophilia Services
Yes
No
Unsure
5.

 If you are willing to disclose it, please state the name of your health insurance carrier.  

Is your insurance plan a "high deductible insurance plan"?  

(This is an insurance plan which generally requires patients to pay for all medical expenses, often $5,000 or more, before the insurance covers any medical bills.) 
Yes
No
  • Comment:

  • 500 characters left.
6.

Does your health insurance company limit the choice of home care pharmacies from which you may obtain clotting factor to only one or two? 
Yes
NO
7.

Are you satisfied with the medical care provided by your hemophilia treatment center (or other place where you receive care for hemophilia)?   

Yes
No
8.

Does your insurance company allow your hemophilia treatment center or program to perform blood studies at the laboratory associated with the treatment center?   
Yes
No
9.

If you are willing to disclose it, state the name of your hemophilia treatment center.
 

50 characters left.
10.

Please state any concerns or opinions you have about the Delaware Valley Chapter, its programs, and its events.
 

1000 characters left.
11.
The Delaware Valley Chapter wishes to obtain your personal contact information in order to keep our member database current. We will use the contact information you provide only to communicate with you by various means, including e-mail, telephone and written mailings. We will not share your personal identifying information with any person or entity not connected with the Delaware Valley Chapter without your advance permission. Your personal information will not be shared with any HPPS participating company or any other entity in the business of selling or marketing health care products and services. We shall make reasonable efforts to maintain the confidentiality of your responses to this survey.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code: