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Submitted By (First Name) *

Age Group

AdultSeniorChildMultiple Ages

Medical Impact *

• Chronic Condition Treatment
• Denied Care Due to Lifetime or Annual Limits
• Disability or Medical Support Services Affected
• Family Health Coverage Loss
• Loss of Health Insurance Altogether
• Maternity and Reproductive Care
• Medicaid Coverage Loss
• Medical Device or Equipment Access Denied
• Medicare Coverage Loss
• Mental Health Care
• Other
• Pre-existing Condition Coverage Denied or Reduced
• Prescription Medications
• Preventive Care Loss
• Switching Doctors Due to Coverage Changes
• Unaffordable Insurance Premiums or Deductibles

Insurance Type

• Employer-Sponsored Insurance
• Medicaid
• Medicare
• ACA Plan
• Off-Exchange Individual Plan
• Veterans Affairs (VA) Healthcare
• CHIP
• Uninsured / No Coverage
• Indian Health Service (IHS)
• COBRA Coverage
• TRICARE
• Student Health Insurance Plan
• Faith-Based/Health Sharing Ministry
• Other / Rather Not Disclose

Date Affected

Map Marker *

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City *

State *

Your Story

Briefly describe how your medical care was affected.

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