Prescription Drug Cost Story
First Name
Last Name
Email Address
Phone Number
City
State
Date of Birth
MM
/
DD
/
YYYY
Age
Race/Ethnicity
How did you get your insurance? E.g. Employer sponsored, Marketplace, Medicare, Medicaid, etc.
What is your work status? E.g. Retired, Full-Time, Part-Time, Unemployed, Student.
What illness or disease do you have that requires prescription medication?
What prescriptions do you take, and how much do you pay for them?
Your full story.
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