Share Your Story

share your story

“I was prescribed the medication that I needed, but my insurance company made me try 5 other treatments first, against the wishes of my docotor”

Share Your Story

*This form shall serve as a release for using my name, image, recordings, video likeness and/or photography in connection with educational, promotional, or advocacy purposes, and I, hereby grant the Fair Health Care VA, its designated representatives and/or officers, directors, and employees (hereinafter called the “Releasees”) permission to use in perpetuity and royalty-free, my name, image, recordings, video likeness, written testimonial, and/ or photograph in connection with the educational, promotional, and advocacy materials of Fair Health Care VA, in any manner and in any medium, as Fair Health Care VA, in its sole discretion, shall deem appropriate or desirable. I hereby waive any right I may otherwise have to approve such use of my name, image, recordings, written testimonial, video likeness and/or photograph, and I release the Releasees from any claim or liability arising out of the reproduction of my name, image, recordings, written testimonial, video likeness and/or photograph, and/or likeness. The territory as to which the Release shall apply is worldwide and I acknowledge the receipt of good and valuable consideration for the rights granted herein. Nothing herein will constitute any obligation on Fair Health Care VA to make any use of any of the rights set forth herein.