Tell Us About Yourself

You may not think you have a story to tell, but you do! We want to motivate other Medicare members just like you to live healthier lives. The best way to do that is to share stories--they can be stories of success, of failure (as long as there is something to learn), of happiness, of life-changes, or any other topic that is compelling to you. Please take a moment to answer a few of our questions. Several of these are optional, but the more info you give us, the better we will know you. So, please, answer as much as you can.

Thank you for your time and your stories!
-The Go365 team

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* 1. What is your name (First and Last)?

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* 2. Are you a member of Go365 by Humana?

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* 3. We may have follow-up questions for you about your health journey, which we will need answered in order to publish your story. Please provide any contact info where you grant us permission to contact you (must provide a minimum of one form of contact).

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* 4. Please write about a time in your life when you were less healthy than you are now. How were you less healthy? What were your habits? What caused you to behave the way you did? If you can't think of a time, please write "N/A."

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* 5. What prompted you to become healthier? Was there a moment you now recognize as your "wake-up call"?

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* 6. What did you do in order to get healthier?

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* 7. OPTIONAL: Have you seen results? Please share details, if you're comfortable doing so.

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* 8. OPTIONAL: What has been the biggest challenge for you on your health journey and how to you address it?

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* 9. OPTIONAL: What or who is your biggest motivation, and why?

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* 10. OPTIONAL: What or who inspires you most, and why?

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* 11. OPTIONAL: If you could give one piece of advice to someone just starting on their health journey, what would it be?

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* 12. OPTIONAL: Please share anything else about your wellness story that you think others might learn from, or find interesting.

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* 13. In order to share your story with others, we need your permission to use what you have shared. Clicking "agree" to the publicity release below will allow us to do that.

By clicking "I agree" below, you agree to the terms of this release. Clicking "I agree" serves as an electronic signature.

Go365
Publicity Release
I hereby voluntarily agree to the use of my story (the “Testimonial”) about my experience using Go365 solutions or services. I acknowledge and consent to the use of my name and likeness together with the Testimonial by Go365, LLC, its affiliates, or agents (“Go365”) in advertising, communications, educational or marketing materials through any medium, or in communications with customers or potential customers, as may be distributed by Go365 or its agents through any medium from time to time.

I represent and warrant that all statements, testimonials and/or endorsements made by me concerning Go365 are true representations and reflect my true opinions and experiences.

I hereby authorize Go365 to edit, distribute and reproduce this Testimonial and to use my name, likeness and/or voice in the public domain in any manner Go365 deems appropriate to advertise, promote, educate and further its proprietary business purposes. I understand that any audio, video footage or photograph taken of me is and shall remain the sole and exclusive property of Go365. I waive any right to privacy that I may have in connection with such use including advertising use.

I understand that the information I provide will be confidential and only authorized individuals will have access to the information.   I have the right to revoke this authorization in writing at any time by sending such written notification to: Humana Privacy Office, 500 West Main Street, PO Box 1438, Louisville, KY 40201-1438. I also understand that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.

I understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under state or federal law. I also understand that the information used or disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by state or federal law.

I understand, agree and acknowledge that I shall not be compensated, via any flat fee and/or royalty for appearing on-camera, for providing the Testimonial and permitting Go365 to use my name, likeness or voice to advertise, promote, educate and further Go365’s proprietary business purposes. I further agree to release Go365 and any of its affiliates, agents, licensees or successors from any liability in connection with such use.

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