patientstories – Patient Story Portal

To ensure that HIPAA and applicable Texas laws are followed, please do not include any PHI identifiers in your submission. PHI identifiers include:

Names
Street address, city, county, precinct, zip code, or other geocodes
Dates directly related to patient (birth/death date, treatment dates)
Phone or fax numbers
Email addresses or URLs or IP address numbers
Social Security numbers
Medical record numbers
Health plan numbers
Account numbers
Certificate/license numbers
Vehicle identifiers, serial numbers, license plate numbers
Device identifiers and serial numbers
Biometric identifiers, including finger and voice prints
Full face photographic images and any comparable images
Any other unique patient-identifying number, characteristic, or code

If you have any questions about whether a story might include PHI, please do not submit it. If you have a question about this process, please contact us at info@txmotherscampaign.com.

I certify that my story will comply with the above guidelines(Required)

Yes

While your name is required for intake, your story will remain anonymous unless we explicitly reach out and receive permission to use your name.

Your Name(Required)

Your Medical Specialty(Required)

City of Practice(Required)

Your Email(Required)

Your Phone(Required)

There are 3 easy ways to submit your patient story: Recording, Writing, or Calling.

How Would You Like to Submit Your Story?(Required)

Recording

Writing

Calling

Writing

Please write your story in the box below and click Submit when complete.

Thank you for your interest in sharing your story. To share your story by phone, please submit this form with the button below. This will send a message to info@txmotherscampaign.com and we'll contact you to set up a call.

Note: Please do not email your story separate from this form as we cannot guarantee your privacy via email.

Calling

Recording

Please note that user video recording is secure and only your audio will be taken into consideration. You can cover your camera if preferred.

What Device Are You Using?(Required)

Desktop or Laptop

Mobile Phone

First click Record Video below. Then click the red record button to start recording. You must also click the red stop button to save your recording.

Pre-record a video on your phone's camera app and upload or record a video here

I clicked the stop button to save my recording(Required)

Yes

Phone

This field is for validation purposes and should be left unchanged.

Patient Story Portal

Author: patientstories