* 1. Contact Information

* 2. Relationship to Individual on Medicaid

* 4. Nature of Disability

* 5. Medicaid Access (Please Check All That Apply)

* 6. Describe how Medicaid coverage has assisted you/loved one:

Please consider the following factors in your response:
-Maintenance health and welfare
-Financial impact
-Ability to live independently
-Personal safety
-Ability to continue to work
-Survival

* 7. What is at risk if the coverage were no longer available to you or if the waiver program became more limited in scope and/or payment

Please consider the following factors in your response:
-Maintenance health and welfare
-Financial impact
-Ability to live independently
-Personal safety
-Ability to continue to work
-Increased emergency needs

* 8. Would you be open to speaking with the media about your experience?

* 9. Story Release

Report a problem

T