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Call Three Reporting Sheet
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Call Three Reporting Sheet
Navigator Name
First
Last
Client Name
First
Last
Client Enrollment Date
MM slash DD slash YYYY
Client Phone Number
Are they still enrolled in their plan?
No
Yes
Not Sure
What is reason they are not still enrolled in coverage?
Did not receive a payment information from the insurance company
Did not receive a benefits card from the insurance company
Received a letter saying I was not eligible/asked for more information
Switched plans or got employer coverage
Cannot afford the monthly premium
Cannot afford the copayments or the deductible when I go to the doctor
Cannot find a health care provider
Other
N/A
(Select all that apply)
Why are they not sure?
Did not receive a payment information for the insurance
Did not receive a benefits card from the insurance
Did not pay - Cannot afford the monthly premium
Cannot afford the copayments or the deductible when I go to the doctor
Cannot find a health care provider
Received a letter saying I was not eligible
Received a letter asked for more information
Other
N/A
(Select all that apply)
Did they receive their insurance card?
Yes
No
N/A
Did any of these apply to them?
Did not receive payment information from the insurance company
Did not receive a benefits card from the insurance company
I moved or changed my address
I received payment information but have not paid the premium
N/A
(Select all that apply)
Have they been to any of the following doctors or health care providers since you enrolled in coverage?
Primary Care Doctor
Specialist
Local Clinic
Urgent Care
Emergency Care
N/A
(Select all that apply)
Will they be returning to the health care provider again this year?
Yes
No
Don't Know
N/A
Do they plan to go to a doctor or health care provider in the next 6 months?
Yes
No
Don't Know
N/A
Why do they not 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
N/A
Would they like assistance with one of the following services?
Getting to know my insurance plan and how to find an “in network” provider
Getting to know my insurance plan and understanding which services are free preventive services
Understanding what to do if my income changes or if I move to another address
Understanding how my health insurance options change if I change jobs, get married or divorced, have a baby.
Obtaining a copy of my 1095-A form to document my health coverage for 2015.
N/A
(Select all that apply)
Did they schedule an appointment after the call?
Scheduled
Not Scheduled
Did you provide education during this call?
Yes
No
Anything else to add about the call?
Δ
