Share Your Story

The Chronic Disease Coalition is always looking for individuals to share their experiences with chronic
diseases and access to health care. Please fill out the form below to

Name*
First Last
Phone
Email*
Address*
City State
Ethnicity
Date of Birth (MM/DD/YYYY)
Date Format: MM slash DD slash YYYY
What chronic diseases or conditions have you or a family member been diagnosed with?
How has chronic disease affected your life?
Have you ever experienced trouble getting your insurance company to cover treatment for your chronic condition?
Have you experienced other types of discrimination as a result of a chronic condition? If yes, please explain.
Is there anything else you'd like to share?
Gender?
- Female
- Male
- Other
I am willing to share my story in the media.
- Yes
- No
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