Share Your Story — RESPOND Act

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Thank you for sharing your story.

Your story has been received and is stored privately. Our team will review it before anything is published — and it will only ever appear publicly in de-identified form, and only if you gave consent. We'll be in touch if you opted in to follow-up contact.

Read Other Provider Stories

Your privacy is protected. All submissions are stored in a secure database. Your personal information will never be shared publicly without your explicit written consent. You control whether your story may be published, used in legislative materials, or shared for follow-up contact.

Provider Information

First Name *

Last Name *

Email Address * Used only for follow-up contact if you provide consent below.

Professional Credentials *

Years in Practice *

Medical Specialty *

State of Practice *

Incident Information

Type of Review or Complaint *

Platform *

Approximate Date of Occurrence *

Your Story

Walk through your experience below. Each part is optional, but a fuller story makes a stronger case — and is easier to publish in de-identified form later. * At least one part is required.

Link to the review or complaint (optional) If the review is public, paste its link here. We may use it to help pre-fill the questions below — you can edit anything that's suggested. Don't include patient-identifying details.

What was posted or said?

What actually happened — and was the post accurate?

How did it affect you, your practice, or your staff?

Did you try to address or resolve it? What happened?

Covered 0 of 4 — every part you add strengthens your story.

It looks like you may have included identifying details (a date, phone number, or email). Please remove anything that could identify a patient — focus on your own experience.

Please tell us what happened — add at least one part of your story above. Do not include patient names, dates of birth, or other identifying patient information.

Supporting Documents (Optional)

You may upload screenshots, PDFs, or images that document the review or its impact. Please remove or redact any patient-identifying information before uploading.

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Click to upload or drag and drop

Screenshots, PDFs, images · Max 10MB per file · Up to 5 files

Permissions & Consent

Please indicate how you authorize your story to be used. All options are optional — unchecked items mean your story will be stored confidentially and used only for internal analysis.

Allow anonymous publication of my story Your story may be published on this website in de-identified form, without your name or identifying practice details, to educate the public and lawmakers.

Allow use in legislative advocacy materials Your story (anonymized or attributed, per your preference) may be included in legislative briefs, testimony, and materials presented to lawmakers.

I consent to follow-up contact A member of our team may contact you at the email provided to gather additional details, clarify your story, or notify you of legislative developments that may affect you.

Please complete the highlighted required fields above.

Your submission is encrypted and stored securely. We will never sell or share your personal information with third parties.