Practitioner Healthcare Survey

Everyone has a health care story. Your story will help us build a strong consumer voice and raise public awareness. A story can change the hearts and minds of the public and elected representatives so that the programs that provide affordable health care to our fellow West Virginians will not see harmful funding cuts and changes. This document will protect your personal information and helps West Virginians for Affordable Health Care keep a record of when and how to share your story. This release allows West Virginians for Affordable Health Care and partners in the Health Care Agenda to use your story and this document secures permission for each use. I hereby release, discharge and agree to hold harmless West Virginians for Affordable Health Care, and its staff and members acting under its permission from any liability relating to the publication of this testimonial. By completing this survey, the respondent gives our Story Collection Coordinator the right to reach out for further information/follow-up and usage of the information provided to help advocate for healthcare policy.