Get Involved

Your Name *

Your Email *

Best time and way to contact you *
Example: Text only, 505-555-5555, before noon

City or Town *

Zip Code *

Tell us a little about yourself *
You can tell us your racial or ethnic group, tribe, about your family, what you like to do, what kind of work you do. Anything you think is good to know to add to your story!

What kind of healthcare coverage do you have currently? *
Check all that apply
UninsuredMedicaidMedicareInsurance through an employer (through your job or the job of a family member)Insurance you bought on my own through an agent or broker (NM Exchange or Bewellnm.com)Other

Are you or your children currently covered by Medicaid? *
YesNoOther

Have you or your children ever been covered by Medicaid at any point? *
YesNo

If you have Medicaid or had Medicaid in the past, how has Medicaid helped you and your family? *
If this DOES NOT apply, or you are some type of healthcare provider or educator, you may write N/A and go to the next question

What would it be like for you and your family if you did not have healthcare coverage? If you do not have coverage, tell us about you and your families’ experiences without healthcare? *
If you are some type of healthcare provider or educator, you may write N/A and go to the next question

If you are also a physician, nurse, clinic employee, home care worker, community health worker or other health provider, please tell us how Medicaid and health care coverage has benefited you or your patients (or what not having that coverage would mean for them):

Are there other barriers you’ve faced to getting good healthcare that you would like to share? *

What do you want you legislator to know about Medicaid and protecting healthcare coverage? *

What do you want your community to know about Medicaid and protecting healthcare coverage?*

Are you willing to speak further with our Healthcare staff about sharing your story? *
YesNo

Do we have your consent to use this information and your story to get the word out on strengthening healthcare for our families? *
YesNo

Do we have your consent to add you to our email list for updates on healthcare policy and our coalition? *
Get connected to what is going on in NM and how our families are changing healthcare. We will never spam you:)
YesNo

Photos make stories powerful! Please provide us a photo or selfie that can be used with your quote.
Uploading your photo AND answering 'Yes' to the consent question above also gives us consent to use your photo to strengthen healthcare.

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