You're the Cure - Affordable Care Act Story Form

Whether you are a patient, caregiver, or medical professional, sharing your story with the media, elected officials, or fellow advocates can make a difference as the American Heart Association/American Stroke Association work to advance policy changes at the local, state, and federal levels that can help Americans build healthier lives.

Please complete the form below to share your story with us. A member of the AHA’s Advocacy team will follow-up with you to discuss opportunities to get involved. Thank you!

Question Title

* 1. Your Information

Name: *

Address: *

Address 2:

City/Town:

State:

ZIP: *

Email Address: *

Phone Number:

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* 2. What is your ethnicity? (Optional)

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* 3. I am a: (Check all that apply)

Heart Disease Survivor

Stroke Survivor

Caregiver

Medical Professional

Other (please specify)

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* 4. Your Health Coverage Comes From?: (Please select all that apply)

Medicare

Medicaid (may be known as medical assistance or by a different name in your state)

Children’s Health Insurance Program (CHIP)

I will/have purchased health care coverage through the Health Insurance Marketplace.

Private Coverage

Employer Coverage

I do not have health care coverage

Other (please specify)

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* 5. Share Your Story:
Information to include-

PATIENTS/CAREGIVERS:
• Your personal experience with heart disease or stroke.
• Challenges accessing/affording the health care coverage you need.
• Benefits from the Affordable Care Act that you've experienced.

Question Title

* 1. Your Information

Question Title

* 2. What is your ethnicity? (Optional)

Question Title

* 3. I am a: (Check all that apply)

Question Title

* 4. Your Health Coverage Comes From?: (Please select all that apply)

Question Title

* 5. Share Your Story: Information to include-PATIENTS/CAREGIVERS:• Your personal experience with heart disease or stroke.• Challenges accessing/affording the health care coverage you need.• Benefits from the Affordable Care Act that you've experienced.

* 5. Share Your Story:
Information to include-

PATIENTS/CAREGIVERS:
• Your personal experience with heart disease or stroke.
• Challenges accessing/affording the health care coverage you need.
• Benefits from the Affordable Care Act that you've experienced.