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Dear HAE Friends,

The HAE Association wants to make sure that all HAE friends have access to new medicines when they are approved. Our research shows that new treatments for rare diseases are very expensive and that health insurance providers need to be "educated" to ensure they will provide adequate and prompt payment.

By filling out this anonymous survey, you will help our efforts to begin the process of contacting health insurance carriers and providing information about HAE and how new treatments will provide us with a better quality of life. Also, by having physician and hospital information, we can also work with specialty pharmacies to make sure medicines are available everywhere there is a need.

We need each and every US HAE patient to fill out this survey, so please make sure you show how many HAE patients in your immediate family are covered by the information you are submitting. Also, please contact everyone you know who has HAE (parents, brothers/sisters, uncles/aunts, nieces/nephews, cousins) and ask them to access our web page (http://www.haea.org), and fill out the survey. Click here to email the link to this survey to your friends and family.


Thank you for participating in the HAEA Survey. Please fill out all the fields below.

The information provided here covers HAE patients in your family
Your Initials:  (optional)
City:
State:
Gender:  Female Male
Age:

Enrolled in HAE Clinical Trial:    Yes No
Currently taking anabolic steroids:   Yes No

How many attacks do you have per year:
 0-10 attacks/year
 11-20 attacks/year
 21-30 attacks/year
 31-40 attacks/year
 41-50 attacks/year
 > 50 attacks/year

Do you have a primary care physician?   Yes No
Primary Care Physician's Name:
Primary Care Physician's Specialty:
Primary Care Physician's Address:
Primary Care Physician's City:
Primary Care Physician's State:
Primary Care Physician's Zipcode:

Do you have a separate physician who treats you for HAE?   Yes No
HAE Physician's Name:
HAE Physician's Specialty:
HAE Physician's Address:
HAE Physician's City:
HAE Physician's State:
HAE Physician's Zipcode:

Do you have Medical Plan Coverage? Yes No
Please provide the complete name of the Medical Plan?: 
Is this plan a Medicare plan?   Yes No
Is this plan a Medicaid plan?   Yes No
Do you have Pharmacy Benefit Plan? Yes No
Please provide the complete name of the Pharmacy Benefit Plan: 
Is this plan a Medicare plan?   Yes No
Is this plan a Medicaid plan?   Yes No


The hospital where you go for HAE attacks and other medical problems.
Primary Hospital Name:
Primary Hospital City:
Primary Hospital State:
Primary Hospital Zipcode:

Do you have another hospital you go to for HAE and other medical problems? Yes No
Secondary Hospital Name:
Secondary Hospital City:
Secondary Hospital State:
Secondary Hospital Zipcode: