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Call Two Reporting Sheet
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Call Two Reporting Sheet
Navigator Name
First
Last
Client Name
First
Last
Client Enrollment Date
MM slash DD slash YYYY
Client Phone Number
Have they received their health insurance card?
Yes
No
Have they been paying their premium?
Yes
No
N/A
Do any of the following apply to them?
Haven’t received my health insurance bill
Can’t afford monthly premium
No longer want health insurance
N/A
Other
(Select All That Apply)
Have they been to any of the following doctors or health care providers since they enrolled in coverage
Primary Care Doctor
Specialist
Local Clinic
Urgent Care
Emergency Care
None
(Select All That Apply)
Will they be returning to the health care provider again this year?
Yes
No
Do Not Know
Do they plan to go to a doctor or health care provider in the next 6 months?
Yes
No
N/A
Why don’t they have plans to go to a doctor or health care provider?
Cannot afford the copayments or the deductible when I go to the doctor
Cannot find a health care provider
I’m pretty healthy and don’t feel like I need to see a provider
Other
(Select All That Apply)
Would they like assistance with one of the following services?
Responding to a HealthCare.gov or Marketplace or Medicaid request for more information
Understanding my options if my income changes or if I move to a new address
Understanding how my health insurance options change if I change jobs, get married or divorced, or have a baby
Finding a primary care provider
Other
(Select All That Apply)
Did they schedule an appointment after the call?
Scheduled
Not Scheduled
Did you provide education?
Yes
No
Anything else to add about the call?
Δ