Please Complete All Fields - Your Data Is Strictly Confidential
First Name:
Last Name:
Angioedema Type
Select
HAE Type I
HAE Type II
HAE Type III
HAE (don't know if Type I or II or III)
AAE
IAE
Undiagnosed
Address:
City:
State:
Choose a State
Outside US / Canada
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
British Columbia
Newfoundland and Labrador
Northwest Territories
Nunavut
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
Prince Edward Island
New Brunswick
Nova Scotia
Yukon
Zipcode
Country:
United States
none
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegowina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, the Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia (Hrvatska)
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and Mc Donald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint LUCIA
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province of China
Tajikistan
Tanzania, United Republic of
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (British)
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
E mail:
Phone:
Date of birth:
month
January
February
March
April
May
June
July
August
September
October
November
December
day
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
year
1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Name of insurance carrier:
Select
AARP Medicare Complete by Secure Horizons Access Access Plus--State Program Aetna Aetna and Medicare Aetna HMO Aetna PPO Aetna PPO - Lockheed Martin Affinity Health Plan ALICO All Kids Family Care Public Insurance (Public) Allegiance Alliance Guardian Alliance Select BCBS Missouri Allied-Medical Mutual AltCare Altius American Insurance Plan American Medical Security Americhoice of NJ Antares (cleveland clinic hosp employees) Anthem Anthem - Blue Cross Anthem BCBS Anthem BCBS - HSA (1500.00) Anthem BCBS - PPO Anthem BCBS Select Anthem Blue Cross Blue Shield Santa Barbara, CA Anthem Senior Advantage Anthom BCBS Arkansas Health ArKids (arkansas childrens medicaid) Assurant Av med AVI Basic Health/Multicare BC of Ca, Pers Choice, Managed by State of Ca BC of North Eastern PA BC/BS North Carolina BCBS BCBS - Medicare (secondary) BCBS - Motion Picture Industry Health Plan BCBS Allegiance BCBS Horizon BCBS MI BCBS Nebraska BCBS of AL BCBS of CA BCBS of Florida BCBS of GA BCBS of GA (Bank of Amer. Employees) BCBS of MA BCBS of MI BCBS of Minnesota BCBS of NJ and Medicare BCBS of Rochester bcbs of south carolina BCBS of Vermont bcbs Pa BCBS PPO BCBS, HMO BCBS, Mountain State BCBS, Personal Choice BCBS-Guaranteed Issue Plan-Blue Options BCBS/Medicaid Blue Care Network Blue Cross Blue Cross Blue Shield fed employee plan Blue Cross Blue Shield of Tennessee Blue Cross Blue Shield PPO Blue Cross Blue Shield, Ill Blue Cross, CA - PPO Blue Cross\Blue Shield of Ala. Blue New England Blue Shield Blue Shield of CA, HMO Blue Shield PPO Blue Capitol Blue Cross in PA Capitol Distric Phy Health Plan Cariten Catastrophic plan only CBCA Admin CDPHP Champ Va - Disab CHIPS (medicaid) CICP Cigna Cigna and Medicare Cigna COBRA Cigna Healthcare - NY Cigna HMO Cigna POS Cigna/Medicare Secondary COBRA Texas Commericial Travelers CVS Caremark Deleware Physicians Care--Medicaid Direct Access plan Don't have insurance Empire BCBS Empire United Health of NY Exclusive Choice Express Scripts Fed Blue Cross Blue Shield First Administrator Inc First Health Freedom Health Care FreedomBlue Gateway german famk GHI - Group Health Inc. GHI-CBP Great West Life Great-West Heathcare Group Health Group Health Options Group Health--Kaiser Harvard Pilgrim Health Care Harvard Pilgrim NH HCF Top Cover Plus Health Alliance Plan Health Alliance--Alliance Select Health America Health Choice Health First Medicare Health Net Health Net CA Health of New England Health Partners Health Tradition Healthlink Healthy Indiana Plan High Deductable PPO - Anthem BC HighMark HIP HMO Blue New England HMSA HMSA PPO Hometown Health HMO Horizon bcbs Ny Horizon BCBS of New Jersey Horizon HMO Horizon PPO Newark, NJ Humana Humana HMO Humana Medicare IL Humana Medicare Supplemental Policy Humana One Humana/Medicare Independent Health Indiana Medical Ingham Health Plan Insur Admin. of America/PCHS Kaiser Kaiser 925-766-6222 Kaiser Senior Advantage suplement to Medicare, GA Keystone Health Plan Central-A Capital Blue Cross Company Keystone Health Plan East KPS Loomis Loomis Health Quest Benefits Div Wyomissing, PA Maine Care (state medicaid) MassHealth MD IPA Medco Blue Cross and Blue Shield Austin, TX MedCost Medi-Cal - California Medicaid Medicaid/Fidelis Medicaid/Medicare Medical Mutual Medicare Medicare & Medicaid Medicare & United America Medicare & United Health Care Medicare / AARP secondary medicare and BCBS Michigan Medicare Part - B Aetna Medicare Primary BCBS Secondary Medicare, Aetna Dupont Medicare, Anthem BSBS Medicare, Healthnet Medicare, Tricare for Life Supplemental Medicare/BCBS Medicare/Blue Care Secondary Medicare/Capitol Blue Medicare/Champ VA Medicare/Harvard Pilgrim Supplement Medicare/Harvard Pilgrim Supplement Medicare/Harvard Pilgrim Supplement Medicare/Harvard Pilgrim Supplement Medicare/Kaiser Medicare/Medicaid Medicare/MVP MercyCare Meri-Health Meritain Metro Plus Commercial mexican company Military Medical Tricare Minnosota Care Molina--(Ohio) Molina-WA--state program MVP MVP Medicaid NCAS Care First Neighborhood Health Network Health None NovaSys Health AR Ntl Elevator Ins using BCBS NYS Empire Plan NYSHIP Empire ODS Ohio Medical Benefits Plan Onenet PPO Oxford Freedom Plan Oxford Insurance PA Access PA Employees Trust Fund/BCBS of PA CIN Prescriber Pacific Source Pacificare HMO PacificCare Health Insurnace Paramount passport PEHP Advantage Pennsylvania Preferred Health Network Perdue Direct Wellsfargo Personal Choice-Univ of PA-HMO PHP, Easter Seals Arc Physicians Health Plan (PHP) Mid Michigan Pompco Preferred Choice Preferred Health Systems Presbyterian Salud Priority Health Providence Health Plan, Portland, OR Qual Care Regence BCBS Regence BCBS of OR Renco (through Union) Sanford Health Plan Scott & White HMO Select Care Plus Shands (University of FL) Signa Signa (COBRA) Siho IN Southern Health, VA St. Lawrence Lewis Counties School Employee Plan Group NY State assistance State Program Synergy Tricare TRICARE Tricare for Life Tricare Prime Tricare Standard TriCare with Humana Tufts TX High Risk Pool - BCBS UDMC for Life Unicare Unison United American Individual Policy United Health Care United Health Care Exclusive Provider Org. (EPO) United Health Care Golden Rule United Health Care Perigon United Healthcare (COBRA) United Healthcare AARP United Healthcare Jackson, WI UPMC USFHP (US family health plan) VA VA-Disability VA/Cigna Viva Plus VT Dr Dynasaur WEB TPA Welpath Westlake Financial Other:
Preferred Hospital for Emergencies:
Attend Conferences:
Select
Yes No Depends On The Location
Help With Organization:
Select
Yes No Maybe In The Future
Family Members With HAE:
Select 0 1 2 3 4 5 6 7 8 9 10
Doctor who treats you for HAE:
Doctor's Address:
Doctor's Phone Number:
Would you say your doctor is knowledgable about HAE?: Select Yes No
Attacks Per Year:
Select
1-10
11-20
21-35
36-60
61-75
More Than 75
Are you interested in clinical trial participation?:
Yes, I'm interested No, I'm not interested
Any other family members (immediate or extended) interested in help or support from HAEA
No
Yes
Immediate Family Members' Names:
Space for Additional Family member Contact Information (names addresses, Phone Numbers, email addresses):