JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Medical Records Class Action
For more information on the WilmerHale Legal Services Center please visit the website for this case here:
https://legalservicescenter.org/medical-records-class-action/
Or go to our general website here:
www.legalservicescenter.org
This case is housed within the Legal Services Center's Safety Net Project.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
If you feel comfortable, please provide the information below so that we may contact you more easily.
Name
Your answer
Phone Number
Your answer
The following questions will help us to determine if you qualify.
Did you for certain assistance or disability benefits? (It doesn’t matter if you were granted it).
*
Yes
No
Unsure
Did you pay for your medical records and/or did you experience a significant delay in receiving the records?
*
Yes
No
Unsure
Other:
Did you indicate to the medical records provider that you were requesting the records to apply for a cash assistance or disability benefits program?
*
Yes
No
Unsure
Were the medical records you requested about medical care you received in Massachusetts?
*
Yes
No
Unsure
Please add any comments about the answers you gave above here, especially if you marked "unsure" to any of the above:
Your answer
If you have any questions for us please include them here.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Google Apps for Harvard.
Report Abuse
Forms