hmo

[p.68]

4a. Does anyone in the family belong to a Health Maintenance Organization or a prepaid group practice plan?

b. What is the name? Record in Table P below. ____

c. Does anyone in the family belong to any other Health Maintenance Organization or prepaid group practice plan?

TABLE P

[MK Note: There are two separate response areas for Plan 1 and Plan 2. Only one response area is represented here, as the information in each area is identical.]

5a. Name of plan ____

b. Who is the policyholder or subscriber of this (name) plan? ____

c. How long has (name of subscriber) belonged to this (name) plane?

ASK FOR EACH PLAN LISTED IN TABLE P


6a. Does -- belong to this (name) plan?

b. Does he ever see a doctor who is not part of this plan?

c. Why does -- sometimes see other doctors? ________

d. Is there any other reason -- sometimes sees doctors who are not part of this plan?

[p. 69]

7a. (Besides ____ plan) Is anyone in the family covered by a health insurance plan which pays any part of a hospital, doctor's, or surgeon's bill?

b. What is the name of the plan? Record in Table H.I. below ____

c. Is anyone in the family covered by any other health insurance plan?

[MK Note: There are three separate response areas for Plan 1, Plan 2, and Plan 3. Only one response area is represented here, as the information in each area is identical.]



8a. Name of plan ____

b. Who is the policyholder or subscriber of this (name) plan?


ASK FOR EACH PLAN LISTED IN TABLE H.I.

9. Is -- covered under this (name) plan?

10. Is there ONE particular doctor or place -- usually goes to when he is sick or when you need advice about his health?

11. Where do you go for this care or advice for --, to a clinic, hospital, doctor's office, or some other place?

If Hospital: Is this an outpatient clinic or the emergency room?
If Clinic: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic?