Answers marked with a * are required.
Please Complete the 11 fields below to submit your story.
1.
Beneficiary Name:
*
2.
Beneficiary State of Residence:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
3.
Beneficiary Zip Code:
*
4.
Beneficiary is enrolled in:
*
Traditional Medicare
A Medicare Advantage (MA) Plan
5.
Your Relationship to the Beneficiary:
*
Self
Spouse
Child
Parent
Other Relative
Non-Relative Caregiver
Attorney or Other Advocate
6.
Your Name (if different from beneficiary):
7.
Your Email Address:
*
8.
Your Phone Number:
*
9.
Please summarize your problem accessing home health care:
*
10.
Can we share this story (without identifying you unless given express permission) with:
*
Media
Legislators
Other Advocates or Advocacy Groups
None, thank you
11.
Are you willing to speak with the media?
*
Yes
No