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Please complete the brief survey below to let us know how we can continue improving our services.

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1. What is the PRIMARY reason that you chose to leave Gateway Health?

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2.If your reason for leaving were to improve, would you reconsider joining Gateway Health?

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3. On a scale of 1-10, with 1 being low and 10 being high, how satisfied are you with your new plan?

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4. Preferred method of contact: Check all that apply

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Gateway HealthSM offers HMO plans with a Medicare contract. Some Gateway Health plans have a contract with Medicaid in the states where they are offered. Enrollment in these plans depends on contract renewal. Gateway Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Gateway Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

ENGLISH: ATTENTION! If you speak English, language assistance services, free of charge, are available to you. Call PA: 1-800-685-5209, OH: 1-888-447-4505, NC: 1-855-847-6430, KY: 1-855-847-6380 (TTY: 711).

SPANISH: ATENCIÓN! Si usted habla español, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. Llame al: 1-800-685-5209, OH: 1-888-447-4505, NC: 1-855-847-6430, KY: 1-855-847-6380 (TTY: 711).

CHINESE: 小贴士：如果您说普通话，欢迎使用免费语言协助服务。请拨 1-800-685-5209, OH: 1-888-447-4505, NC: 1-855-847-6430, KY: 1-855-847-6380 (TTY: 711).

Y0097_965 Accepted