failfirst-join

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
I am a:*
Which of the following health conditions apply to you or the person(s) you are advocating on behalf of?
- Ankylosing Spondylitis
- Cancer
- Cardiovascular Disease (CVD)
- Chronic Pain Syndrome
- Fibromyalgia
- Gout
- High Cholesterol/Familial Hypercholesterolemia (FH)
- Inflammatory Bowel Disease (IBD)/Crohn’s or Ulcerative Colitis (UC)
- Juvenile Arthritis
- Lupus
- Migraine
- Osteoarthritis
- Osteoporosis
- Psoriasis
- Psoriatic Arthritis
- Rheumatoid Arthritis (RA)
- Scleroderma
- None of the Above
- Other
Select all that apply
If Other, Please explain
Please tell us what motivated you to join our network
Have you engaged in advocacy through any of the following activities?*
- Contacted elected officials
- Written letters to elected officials
- Signed or created petitions
- Posted on social media
- Wrote op-eds or letters to the editors
- Conducted television interviews
- Conducted radio interviews
Select all that apply
One form of advocacy is speaking out. Are you comfortable speaking publicly?*
How do you envision yourself advocating with us?*
What medications do you or the person(s) you advocate for currently take?
Why is this important? We advocate for many policies that involve access to treatments. Learning which medications our patient communities are prescribed assists our efforts and allows us to inform you of related advocacy opportunities.
What form of insurance do you have?*
- Medicare and/or Medicaid
- Other government insurance (e.g., Tricare, CHAMPVA)
- Private insurance (purchased privately or through an employer)
- Other
- I don’t have health insurance
- I don’t know
Why is this important? We advocate for fairer health insurance policies. If we are aware of your current health insurance coverage type, or the person(s) you advocate on behalf of, we will be able to get you involved sooner.
Have you or the person(s) you advocate for experienced any of the following?*
- Try and fail on a medication before your insurance would cover what your doctor originally prescribed (Step Therapy)
- Been forced to change medication for non-medical reasons due to your insurers’ new policies. (Non-Medical Switching)
- Been denied access to a co-pay assistance card of manufacturer provided program.
- Been made to wait weeks before your insurance company covered your prescription, test, or procedure.
Why is this important? By understanding which barriers our patient communities face, we can better advocate on these issues and, ultimately, promote change.
How did you hear about us?*
- Yes! Sign me up for the 50 State Network Newsletter!

Changes to Step Therapy May Impact You: