HCFANY Story Form

1. Story Form

The Health Care For All New York Campaign needs your help to show why New Yorkers need a better health coverage system, and how it should be changed. If you have ever had to go without medical care you needed, couldn’t afford to fill a prescription, or had to stop seeing a doctor you liked because he wasn’t in your plan’s network, you may have a story that could educate others about the problems of our health care system.

Personal stories can make complicated policy issues understandable. Reporters and policymakers find stories useful to illustrate the everyday struggles we face in order to get health care. If you are willing to share your story, with or without your name on it, please fill out this form.

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* 1. Does your story involve any of the following issues (mark all that apply)

Delayed or didn’t get medical care because you didn’t have insurance.

Had insurance, but delayed or didn’t get medical care because your insurance didn’t cover it.

Have to pay too much for health care even though you have insurance.

Got some of the care you needed, but not enough.

Need medicine, medical supplies, or equipment (like a wheelchair) that your insurance doesn’t cover.

Got the care you needed, but you are having trouble paying for it.

Had to change doctors because of your insurance plan

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* 2. Did you have insurance when the story took place?

Yes

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* 3. If Yes, to Question 2, what type

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* 4. If you are working, do you get health insurance from your job?

Yes

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* 5. How many people live in your home, including you?

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* 6. Does everyone in your home have insurance?

Yes

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* 7. Please check off all the ways below that the Health Care For All New York Campaign ("HCFANY") can use your story:

with your real name

with a changed name

in news media

in reports, letter, testimony or other HCFANY writings

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* 8. We ask for your contact information so we can call or email you if something isn’t clear, and to know where your story took place. We welcome your story even if you don’t want to fill in the other blanks below.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

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* 1. Does your story involve any of the following issues (mark all that apply)

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* 2. Did you have insurance when the story took place?

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* 3. If Yes, to Question 2, what type

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* 4. If you are working, do you get health insurance from your job?

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* 5. How many people live in your home, including you?

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* 6. Does everyone in your home have insurance?

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* 7. Please check off all the ways below that the Health Care For All New York Campaign ("HCFANY") can use your story:

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* 8. We ask for your contact information so we can call or email you if something isn’t clear, and to know where your story took place. We welcome your story even if you don’t want to fill in the other blanks below.

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* 9. Your Story: