Share Your Story

Email Address *

First Name *

Last Name *

City *

Zip *

Phone *

Do you currently have health insurance? *
YesNo

If yes, who is your health insurer?

If you do have coverage, are you able to afford your premiums, deductibles, and/or co-pays? *
YesNo

Are you or a loved one avoiding accessing healthcare, due to the costs, or sacrificing other necessities - such as food or rent - to pay for healthcare? *
YesNo

What is your healthcare story? *

What's the best way to contact you to discuss your story?
EmailPhoneText

Would you be willing to speak with the media, lawmakers, and others about your story? *
YesNoMaybe

Would you be willing to allow Healthy California to share your story in letters, press releases, or social media campaigns? *
YesNoMaybe

* Required

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