| Personal information isn't required but be assured your information will be kept strictly confidential! Please use this form as a guide for your letter. Address letters or emails to NYS DOH Commissioner Richard Daines. For Snail Mail: NYS DOH Commissioner Richard Daines, Room 1401 Corning Tower, Empire State Plaza, Albany, NY 12237. To insure that your letter gets seen, please cc to David Sullivan at the same address above or send an email copy to: mmj02@health.state.ny.us | |
| Please enter your Name, Street Address and City, followed by your State (New York) and Zip Code and Phone Number | |
| Email Address: | |
| Please Note: If more than one family member has Lyme or other tick-borne diseases, please include details. FIRST QUESTION: Did you see a tick bite? (mention congenital Lyme disease if Lyme disease not from a tick bite) | |
| (2) Did you see a bull's eye or other rash? | |
| (3) Approximately how long were you sick before being diagnosed with Lyme disease and/or tick-borne diseases? | |
| (4) How many doctors (or specialists) did you see and what kinds of tests (cite results) did you have done before you were diagnosed? Was yours a clinical diagnosis? | |
| (5) What misdiagnoses were you given? | |
| (6) What are the tick-borne diseases that have been transmitted to you or your child through a tick bite? | |
| (7) How many times have you or your child been infected with tick-borne diseases? | |
| (8) How many tick bites have you or your child had and were they at one time or at different times? | |
| (9) Briefly describe your symptoms, your child's symptoms. | |
| (10) What was the treatment and length of time of treatment? | |
| (11) Were your symptoms completely resolved or partially resolved? | |
| (12) Describe the way your life, children's lives have been affected by Lyme and tick-borne diseases. | |
| Additional Comments; You can also include history of Insurance Denial here. | |
| If you would like us to forward your answers in this form as your testimony to Commissioner Daines, please answer "Yes, Please Forward." Thank you very much from Empire State Lyme Disease Association, Inc. We will update you on the progress being made. | |