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Name
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First Name
*
Last Name
*
Member ID (IN)
*
Plan
*
PHC CA
PHP CA
Email
Phone
Address
*
Address Line 1
Address Line 2
City
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California
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Armed Forces Europe
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Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
How do you feel about how often PHP/PHC California contacts you by mail?
*
Too much
Just right
I want to hear from PHP/PHC more!
How do you feel about how often PHP/PHC California contacts you by phone?
*
Too much
Just right
I want to hear from PHP/PHC more!
In addition to regular U.S. Mail, how would you like PHP/PHC to contact you as needed? (Please check all that apply.)
*
Call
Text
Email
Other:
Other Value
What topics would you like to learn more about? (Please check all that apply.)
*
Health & wellness issues (like cancer, allergies, nutrition, heart health, HIV/AIDS, etc.)
PHP/PHC programs
Health benefits and services from PHP/PHC (like access to care and medicine, etc.)
Community Advisory Committees (CACs) & Health Promoters
Other:
Other Value
Would you prefer to get your Positive Outlook Member Newsletter electronically by email?
*
Yes, please send to the email provided in this form.
No, I like it in print.
Are you satisfied with the service PHP/PHC provides?
*
I am satisfied.
I am not satisfied. If you are not satisfied, please call our Member Services Department and let us know how we can better serve you. We are here to help you!
If satisfied, what do you like most?
Does PHP/PHC provide you with what you need to help you be as healthy as possible?
*
Yes.
No. If no, what would you like PHP/PHC offer to help you be healthier?
What devices do you use? (Please check all that apply.)
*
Smartphone (for example, iPhone or Galaxy)
Mobile phone
Laptop computer
Tablet computer (for example, iPad)
Printer ¨ Desktop computer
Would you like to be featured in future (PHP/PHC California) campaigns to share your experiences as a satisfied member?
*
No thank you.
Yes!
If you would like to be featured, how would you like to be contacted?
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