IVIG Story

Country Code ("1" for US and Canada)

Area Code or Intl City Code (if reqd.)

Your Local Number

You CAN Make a Difference
In the Foundation's continuing effort to make your voices heard in Washington DC, in statehouses across the United States and within the international community, we need your help.

If you have been denied the IVIG treatment your physician prescribed, if your insurance company won't reimburse a good part of your expenses for IVIG treatments or if you have had other problems obtaining the treatment you need, we want to hear your story.

Name
Address
City, State, Postal Code Country

Phone Numbers:

Phone:

E-mail:

Would you permit us to use your name in our advocacy efforts in both Washington, DC
and in State capitols?

	Yes
	No

Do you have GBS,
CIDP or a variant?

	GBS
	CIDP
	Other (please name your disorder)

Explain in as few words as possible what went wrong with getting the IVIG treatment your neurologist prescribed. Be as specific as possible.

Thank You!

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The Holly Building - 104 1/2 Forrest Avenue - Narberth, PA 19072
Phone: 610-667-0131 - Fax: 610-667-7036
Toll Free: 1-866-224-3301