Share Your Story - Formstack

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Share Your Story

Name*

First Name*

Last Name*

Organization

Address*

State

ZIP Code

Email*

Phone

Have you ever used a copay or manufacturer assistance card to help pay for your medication?

Yes No

What is your insurance status?

I am insured through my employer/partner's employer/parents I am insured through the individual marketplace Medicare Medicaid I am uninsured

Which disease is your story about?

Allergies Asprin-Exacerbated Respiratory Disease (AERD) Asthma 特应性皮炎/湿疹 Chronic obstructive pulmonary disease (COPD) Urticaria

Is your story about one or more of these topics?

Co-pay accumulator programs Out of pocket costs Prior authorization Step therapy 袜子的lbuterol in Schools Telehealth

Who is this story about?

Myself My family My patient

Other: Other Value

Your story

Consent:I affirm that I am at least 18 years of age and allow Allergy & Asthma to contact me about legislative opportunities in my state or on the federal level to engage on in my areas of interest and experience.

I consent to Allergy & Asthma Network using my story

Yes No

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