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This brief survey takes about 5 minutes and helps us understand whether support programs may be available to assist with things like food, transportation, utilities, housing, or other everyday needs.

Your responses are confidential and used to help connect you to relevant resources

If support is available based on your responses, an Aeroflow Care Compass team member may follow up with next steps.

Call Now: 855-586-7233

Health & Social Support Questionnaire

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Sections

Patient Information

I am the...

PatientParent/Caregiver of a patient

Patient First Name

Patient Last Name

Patient DOB

Ethnicity

Hispanic or LatinoNot Hispanic or LatinoI choose not to answer this question

Race (Check all that apply)White or CaucasianBlack or African-AmericanAsianNative HawaiianPacific IslanderAmerican Indian or Alaska NativeOther

Phone

Please select the answers that apply to you or the patient. Help us support your health and improve care for all patients by filling out this form. We will do our best to connect you with resources but may not be able to provide direct assistance. Your answers are confidential. We may use general information that does not identify you from these answers for health plan reporting. Thank you!

I understand that my answers are confidential and may be used for health plan reporting.

I consent or, if under 18 years of age, my legal guardian consents to being contacted by Care Compass via phone, text message, or email.

I also authorize Care Compass to use and disclose my information, as necessary, to coordinate services, facilitate communication, and engage with healthcare providers, health plan, or other relevant parties, in accordance with applicable privacy laws, including HIPAA.

What state do you live in?

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Main Insurance

None/uninsuredMedicaidCHIP MedicaidMedicareOther public insurance (not CHIP)Other Public Insurance (CHIP)Private Insurance

Mission

Our Mission is to enroll qualified patients into government-sponsored social resources, ensuring access to essential programs and improving health outcomes.

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