Hemophilia Council of California- HEALTHCARE ACCESS ISSUE REPORT FOR PATIENTS WITH BLEEDING DISORDERS

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Patient Name (optional)

Patient’s county of residence

Age

Gender

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Bleeding disorder:

Hemophilia

von Willebrand disease

Other:

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Type of insurance:

Medi-Cal

CCS

GHPP

Medicare

Private (please list name of plan in comments section)

Don't know

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Who is completing this report?

Patient

Parent

Caregiver

HTC Staff Member

Specialty Pharmacy Representative

Chapter

Other:

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Name of medical facility where problem occurred (optional)

Physician name (optional)

What is the best way to communicate with you if more information is needed? (optional)

Phone

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Email or Phone Contact Information (optional):

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