The Chronic Disease Coalition is always looking for individuals willing to share their experiences with chronic illness and access to care. Please fill out the form below to share your story. Some might be shared on our website or social media.

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* 1. First Name

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* 2. Last Name

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* 3. Contact Information

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* 4. Gender

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* 5. Ethnicity

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* 6. Date of Birth (MM/DD/YYYY)

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* 7. What chronic diseases or conditions have you been diagnosed with?

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* 8. How has chronic disease affected your life?

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* 9. Have you ever experienced trouble getting your insurance company to cover treatment for your chronic condition? If yes, please tell us about it.

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* 10. Have you experienced other types of discrimination as a result of a chronic condition? If yes, please explain.

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* 11. Is there anything else you'd like to share?

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* 12. I am willing to share my story in the media.

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