Response

First Name

Last Name

Zip

Cell Phone

Patients, Share Your Story

Have you been pursued by a hospital trying to collect medical debt? If so, Senator Bernie Sanders (I-Vt.), Chairman of the Senate Health, Education, Labor, and Pensions (HELP) Committee, wants to hear your story.

The submissions are confidential and will help the Committee investigate how hospitals fail to provide benefit to the communities they serve. Please note that the Committee will not share your story publicly unless you give permission below.

1. Tell us your story about the medical care you needed and how the hospital pursued their bill. If you previously or currently have medical debt, please include as much detail as you can.

2. Do we have permission to share your story?

Yes, with my name

Yes, without my name

3. When did this happen?

4. What is the name of the hospital that provided the medical care?

5. What city is the hospital in?

6. What state is the hospital in?

7. Did you have health insurance when this happened?

Yes

8. Is there anything else you would like us to know?

9. May we follow up with you regarding your story?

Yes

10. Help us categorize your response. Do any of these apply to your story? Please check all that apply:

The medical care provided was for a child

The medical care provided was for a pregnant person

My debt was turned over to a debt collector

I have had difficulty getting care at the hospital because I owed them money

The hospital gave me information about how I could get free or reduced price care to help pay my medical bill

I applied for free or reduced price care to help pay my medical bill

I have or do work for this hospital

The hospital has tried to or does attach my wages to pay the debt

I have lost my home, my job, or other important assets as a result of this debt