#MyAccessMatters

Together our personal stories are the most powerful tool we have in our fight to protect and expand access to quality health care and supplies for people who have had ostomy or continent diversion surgery. Join our national advocacy efforts and make a difference on a larger scale.

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* 1. Individual's/Family Member's Basic Information (Your contact information will not be shared.):

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* 2. If you use Social Media, which outlets do you use?

  Yes No
Facebook
Twitter
Pinterest
Instagram
LinkedIn

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* 3. Do you participate in Medicare?

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* 4. Do you currently have health insurance?

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* 5. If yes, which insurer do you have?

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* 6. Are your ostomy supplies covered by insurance?

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* 7. If yes, what percentage of your ostomy supplies is covered?  (If no ostomy coverage, please answer "N/A.")

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* 8. If not 100% full coverage of ostomy supplies, what are the limitations or restrictions on coverage?  (If you do not have any coverage of these supplies, please answer "N/A.")

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* 9. If not full coverage, how much do you pay out-of-pocket for your ostomy supplies in a typical month?  (If you do not have coverage, please answer "N/A.")

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* 10. How much money, in U.S. dollars, do you spend on healthcare in a typical month? (Count all healthcare-related costs, including health insurance premiums, deductibles, copays, co-insurance fees, and any other out-of-pocket expenses for medical, dental, or vision services and medications.)

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* 11. Have you tried to get coverage for your ostomy supplies in the past and been denied?

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* 12. Please share your story with us! Some examples of what you can share with us include: a) Why do you need access to your specific pouching system or accessory?; b) Why is this particular technology so important to your health?; c) Describe any experiences that may have arisen from having a prescribed ostomy appliance not fully covered by your insurance and the financial burden, if any (e.g., high medical debt)?; d) How did you take care of your health needs to make-up for the lack of coverage/access?

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* 13. If you could say one thing to a policymaker about the importance of access to the ostomy supplies that have been specifically prescribed for you, what would it be?

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* 14. Please share your photo with us. Putting a face to a statistic is a powerful advocacy tool. If you can share a photo say yes, and we will follow up with you via e-mail.

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* 15. Are you interested in becoming a volunteer by joining the UOAA Advocacy Network?

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* 16. Please sign up for the UOAA Monthly E-Newsletter to keep up with the latest news about the ostomy community, national advocacy efforts and the UOAA.

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* 17. Release for Advocacy Stories:

I grant United Ostomy Associations of America, Inc. (“UOAA”) permission to use my story and/or likeness and any photographs provided in any and all of its publications or media, including website entries, without payment or other consideration.  I understand and agree that I have submitted these materials to UOAA voluntarily and they will become the property of UOAA and will not be returned.

I irrevocably authorize UOAA and/or its agents to edit, alter, copy, exhibit, publish, distribute or use my story for advocacy purposes or for any other lawful purpose.

In addition, I waive the right to inspect or approve the finished product, including written or electronic copy, wherein my information appears.

Additionally, I understand that I will not receive any royalties or other compensation arising from or related to the use of the information.  I hold harmless UOAA and/or its agents from any claims, demand, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization or the use of my story, likeness, and photos.  I certify by my signature that I am at least 18 years of age and am competent to contract in my own name.

By checking this box and typing my name below, I acknowledge that I have read, fully understand, and agree to the contents, meaning, and impact of this release.

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* 18. Thank you! By sharing your story, you are helping us speak not just on your behalf, but also on behalf of people who may be facing the same issues. You can help us change the future for thousands of other people who are living with ostomies and continent diversions. Feel free to add any other comments here.

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