MNsure Story Collection Tool Survey

Thank you for your interest in sharing your MNsure story. By taking a few minutes to share your story, you're helping to educate Minnesotans about the importance of health care.

Consumer and Assister stories may be used in MNsure's digital marketing by way of our website, Facebook, Twitter and YouTube, and you can request that your story be taken down at any time. You are not required to submit your story to MNsure.

Before submitting your story, please be sure to review the authorization at the bottom of this form. MNsure is requesting your permission to share the information you provide publicly.

(Please note: MNsure values all types of feedback. If you are a consumer wishing to share a problem or challenge, please call 651-539-2099 (855-366-7873 outside the Twin Cities) or email publicfeedback@mnsure.org so your issue can be followed up with more effectively by appropriate staff.)

Please provide the best contact information for you. This information will not be shared without your consent.
An assister can submit on behalf of a consumer. If the consumer prefers not to share all of their contact information, the assister should enter the consumer’s first name with the assister’s city and email/phone number.

First and Last Name

City

Email Address and/or Phone Number

How has enrolling through MNsure impacted you and/or your family?

Which type of plan or program did you enroll into?

A qualified health plan (private plan through an insurance company) with a tax credit

A qualified health plan (private plan through an insurance company) without a tax credit

MinnesotaCare

Medical Assistance or MA (also known as Medicaid)

I am not yet enrolled in a program or plan, but intend to complete the process very soon.

I am not sure

If applicable, please enter the name of the MNsure assister who helped you and the organization they work for.

If applicable, in what ways did the assister help you?

I authorize MNsure to release the following information about me:

The information I provided in response to the questions above; and
A still or recorded image of myself, if provided.

I understand the following:

I am not required to provide this information; there are no negative consequences if I choose not to do so.
I am agreeing to allow MNsure to release the information I provided; I do not have the right to review or approve the product created from the data released; and I will not receive compensation of any form for the use of this data.
Data held by MNsure about me are classified as private, however my story may be released to the public. As a result, people who see this information may pass it along to others.
MNsure may seek additional information from me to verify my identity before releasing the data.
I may revoke this consent at any time by emailing communications@mnsure.org. My revocations will not affect any information that has already been released by MNsure.
I am giving this consent voluntarily and understand the consequences of giving this consent.

Do you agree to share the above listed information (underneath Authorization/Consent)?

I agree.

I do not agree to share the above information.

I agree to share some of the above information but would like to be contacted for clarification.

General Consent and Authorization for Release of Information

By clicking “submit” below you are indicating that you are at least 18 years old, have read the above information, and consent voluntarily.

Thank you for taking the time to share your experience with us.