Medicaid Video $100 Raffle

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Thank you for your interest in sharing your experiences with Medicaid. If you would like to enter the $100 raffle, please complete the form below.

If you have questions or need assistance in completing this form, contact yourmedicaidstory@legalcouncil.org.

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First Name *

Last Name *

Address *

Email Address *

If you do not have an email address, type "None."

Phone Number

Video Release Agreement *

By submitting a video, you understand your video will be made public. If at a later time you wish for your video to be removed from public channels, you can contact yourmedicaidstory@legalcouncil.org. Please allow up to 2 business days for a response.

I acknowledge that my video will be made public.

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