Story Collection Form

Story Collection Form

During the 2018 General Assembly Session, Virginia legislators will consider several bills which would expand Medicaid eligibility to Virginians at or below 138% of the Federal Poverty Level(FPL) ($16,642 for one, $33,948 for a family of 4). Medicaid expansion would providenearly 400,000eligibleadult Virginians with health coverage, including hospitalizations and doctor visits.

To help legislators understand whothese Virginians are and why health insurance is so import to them, we need your help. Please identify 2 patients with incomes at or below 138% FPL who have compelling situations, e.g. the cost of medicines they need would be a significant percent of their income and unaffordable without the help of your medication assistance program.

Please select patients who are working (full or part time). It may help to find someone who couldn’t obtain needed medicines before finding your organization and getting help.

Please send to Michelle Barnett (email: )
as soon as possible and no later than Friday, February 9, 2018.

Thank you!

Name of Person Gathering Story: ______

Agency: ______

Patient Name: ______Gender: ______Age: ______

Patient’sEmail:______

Patient’sPhoneNumber: ______(Is this a cell? Yes / No)

Preferred contact method: email / phone (circle one)

Patient Annual Household Income: ______

Is it ok to contact the patient with additional questions? Yes / No (circle one)

If yes, through you  or directly ?

Has the patient ever had health insurance? Yes / No (circle one)

If yes, how, when,and why did s/he lose/drop coverage?

Has the patient ever delayed medical/dental/behavioral health care because s/he was uninsured?If yes, please describe.

Has the patient ever had to be admitted to the hospital or go to the emergency room while uninsured? If yes, please describe why, how often, and what happened.

Is or has the person been unable to work (or is working reduced hours) or participate in things s/he enjoys (sports, family activities) due to untreated illness?

Does or did the patient have untreated dental or behavioral health conditions that negatively impacted his/her life? If yes, please describe.

Is there anything else that is important to know about the negative impact lack of health insurance has had on the person, family or their life? Or, the positive impact that coverage would have?

How will the patient’s life change by having health insurance / Medicaid?

Permission to Share Information

I give permission for the Virginia Health Care Foundation to use or publish my story to education legislators and others about the importance of health insurance coverage for me and others. I understand that the Foundation may publish my testimonial through any and all media. It may also edit it as appropriate and required for different audiences. I hereby release, discharge and agree to hold harmless the Virginia Health Care Foundation and its RxRelief Virginia Medication Assistance Caseworkers acting under its permission from any liability relating to the publication of this information.

Signature ______Date______

Name (printed) ______Witness______

Address ______

City/Town/Zip code ______

___You may use my story with my full name & town

___You may use my story with my first name & town

___You may use my story, but not my name

Return to:

The Virginia Health Care Foundation

707 East Main Street, Suite 1350

Richmond, VA 23219

Fax: 804.828.4370