Share Your Medicaid Impact Story

Florida's Agency for Health Care Administration's (AHCA) rule stripping Medicaid coverage for gender-affirming care goes into effect on August 21, 2022, officially ripping life-saving care from thousands of vulnerable Floridians. If you are impacted by this new rule on gender-affirming care through Medicaid, we want to know if you're willing to share your story not only with the public but also with the court.

Disclaimer: The information that you share with us will be accessible only to Equality Florida and our partner Southern Legal Counsel, which is a statewide public interest civil rights law firm in Florida. The information collected through this questionnaire will not be shared publicly or with third parties without your consent. The purpose of this questionnaire is to collect information about, and to get into contact with, Florida Medicaid recipients who will be impacted by the ban on Medicaid coverage of gender-affirming care. There is no guarantee being made regarding legal representation, and no attorney-client relationship is being formed when you complete this questionnaire.

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Affirmed First Name: *
Affirmed Last Name: *
Affirmed Gender:
Are you a Florida resident: *
Do you identify as transgender or nonbinary?
Clear selection
Are you filling this out on behalf of your child who identifies as transgender or nonbinary?
Clear selection
Do you have Medicaid:
 *
Are you filling this out on behalf of your child who has Medicaid?
Clear selection
If you or your child have Medicaid, what Medicaid plan do you have (examples: Sunshine Health, United Healthcare, Molina, Simply Health, CMS, Humana):
What is the basis upon which you qualify for Medicaid:
How long have you had Medicaid health insurance (approximation is fine):
What gender-affirming care do you currently receive through Medicaid (i.e. blockers, hormone replacement therapy, any surgeries or procedures, etc.):
Is your gender-affirming care currently covered by your Medicaid plan?
Clear selection
Have you been diagnosed with Gender Dysphoria?
Clear selection
If so, when (approximately) were you diagnosed?
Who is your current medical provider through which you receive gender-affirming care:
How will losing access to Medicaid coverage for gender-affirming healthcare impact your life?
Are you willing to speak with a lawyer regarding a potential challenge to the Medicaid ban if it is determined that you would be a good fit for being involved in any such legal challenge?
 *
Disclaimer
There is no attorney-client relationship being formed by you filling out this questionnaire, nor any guarantee that you will be contacted by a lawyer. Southern Legal Counsel is simply seeking to speak with people who are impacted by this discriminatory new ban, but there is no guarantee of representation. 
What is your preferred phone number:
 *
What is your email address:
 *
What is your physical address:
 *
What is the best way to get in touch with you: 
 *
Required
What is your age, or the age of your minor child, if you are filling this out on behalf of your child:
How do you describe your race and ethnicity?
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