Family Stories
Please print this form for family stories from California Foundation for Independent Living Centers.
State Budget Cuts
Story Bank Form
First Name: (Optional) _______________________________
Last Name: (Optional) _______________________________
Address: (Optional) ______________________________Zip Code: _____________
Phone # ___________________ E-mail address: ____________________________
Language: English_____ Spanish_____ Other_______
May we contact you for additional information? Yes ____ No _____
Can we use your story in the media? Yes ____ No _____
Best time to contact you: ______________________________________
Please answer the following questions:
I am at risk of losing the following services as a result of the State Budget Cuts:
____ 1. In Home Supportive Services (18% Reduction in domestic services hours)
_____ 2. Medi-Cal: Optional Benefits. Below is a list of optional benefits please check the services you currently use.
___ Acupuncture ____ Adult Dental ___ Audiology ___ Optometry ___ Optical ___ Chiropractic ___ Podiatry ___ Psychology ___ Speech Therapy ___ Incontinence Creams and/or Washes
_____ 3. Medi-Cal Provider Rate (My doctor/provider will no longer accept my Medi-Cal as a result of the budget cuts)
_____ 4. Other (Examples: Cuts to Cal Works, Healthy Families, SSI/SSP Cost of Living Adjustments, etc.)
I agree to do the following to participate in the following activities:
___ Local newspaper Interview ___ T.V. Interview ___ Call my legislator ___ Write a letter to my legislator ___ Visit my legislator ___ Testify at a legislative hearing
FACTS ON THE POTENTIAL STATE BUDGET CUTS:
The Governor released the proposed 2008 – 2009 state budget and in it there are several cuts to services that people with disabilities. CFILC is advocating against the following three:
1) Doctors/providers who accept Medi-Cal will take a 10% cut in their reimbursement from the state. Effective July 1, 2008
2) Medi-Cal, “Optional benefits”, which including dental, acupuncture, audiology, optometry, optical, chiropractic, podiatry, psychology, speech therapy, and incontinence creams and washes will be cut.
3) The budget proposes an across-the-board 18% reduction in In-Home Support Services domestic and related service hours. Effective July 1, 2008 for all consumers.
Please tell us how these potential cuts will impact your life:
By signing this form I am giving you permission to contact me and or to use my story.
___________________________________ __________________
Signature Date
Please fax or email completed forms to the California Foundation for Independent Living Centers at (916) 325-1699 or christina@cfilc.org