Medicaid Petition Form

First and Last Name

How long have you been a patient? How long have you been a patient? Less than a year Between 1-5 years Between 5-10 years 10 years or longer

How would you rate your experience at Gretna Medical Center? How would you rate your experience at Gretna Medical Center? Dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Very satisfied

What type of medical services do you receive at Gretna Medical Center (Select all that apply) What type of medical services do you receive at Gretna Medical Center (Select all that apply) Medication Management and/or Refills Acute Problems / Urgent Care Services Chronic Problems Pediatric Services/Immunization Managment Wellness Visits/Contraception Management Other

How has the current situation affected you?

Do you want to remain anonymous? Do you want to remain anonymous? yes no