Brain Tumor Drug Copayment Assistance Program

Copayment Assistance Program Survey!

This is annonymous, but if you would like a response, fill out our feedback form!

Are you a:	Brain Tumor Patient Caregiver Friend Pharmacy Patient Advocate Doctor Other (Explain in last comment box)
Did you (or your patient) receive a grant from us?	Yes No- did not apply yet No- waiting for decision No - was denied
How were the instructions on the website and application? (Select all that apply	Perfect Hard to understand Too long Not enough detail Did not read them A video explanation would be better
How was the application process? (Select all that apply)	Perfect Too hard to gather documents and signatures Had trouble typing into form Application is too long Do not have access to fax Took too long to get decision Too nitpicky on documentation
How was the claim processing? (Select all that apply)	Perfect Too hard to get the receipt Took too long to get paid Too nitpicky on documentation Would prefer electronic payment Too much paperwork sent with the check Paperwork sent with the check too hard to understand
If you spoke with us (or tried to) on the phone: (Select all that apply)	Perfect Left message and was not called back Left message and was called back next day or worse Left message and was called back same day Phone was answered quickly My questions were answered clearly My questions were not answered clearly Did not try to call
The qualifications for our program are: (Select all that apply)	Perfect Too generous on income Too strict on income limits Tumor types too restricted Treatment types too restricted Insurance requirement stopped me from applying Annual $5,000 limit is too low
Overall usefullness of our program:	Extremely Somewhat Little Not at all
Comments and suggestions to improve the program: If you received a letter from us recently, please tell us the postmark date from the envelope and the date you received the letter. If you received a "Brain Tumor Guide" from us, let us know if it was useful to you and if you think we should continue sending it out with the first claim payment.
Ethnicity (Optional):	White Hispanic or Latino Black or African American Asian / Pacific Islander Other (specify in comments above)
Education (Optional):	No schooling completed Nursery school to 8th grade Some high school, no diploma High school graduate, diploma or the equivalent Some college credit, no degree Trade/technical/vocational training Associate degree Bachelor's degree Master's degree Professional / Doctorate degree