Northern IM Consortium Complaint Form

In the interest of resolving your concern, please complete this form. Attach additional pages, if necessary. If you would like help filling out the form, please let us know.

Does your concern relate to the denial, reduction, or termination of benefits? Check affected program:

0 Medicaid/BadgerCare+ 0 FoodShare 0 Child Care

0 Other: please identify ___________

(Note: You may also file a Request for a Fair Hearing with the Division of Hearings and Appeals. Requests for hearing must be made in writing to the Division of Hearings and Appeals, P.O. Box 7875, Madison, WI 53707-7875, and should include: Your name, mailing address, a brief description of the problem, which county or state agency took the action or denied the service, your social security number and your signature).

Does your concern relate to the timeliness of benefits? 0 Yes 0 No

Does your concern relate to staff from this Consortium? 0 Yes 0 No

If yes, please identify: ___________________________________

Have you talked to that person? 0 Yes 0 No

Please describe your complaint:

Where did this happen:

When did this happen:

What do you want the Consortium to do in response to your concern:

Name: Date:

Address: Phone:

Name, address, and phone of person completing form (if different):

Please return this form:

By Mail: Shawna White, Resolution Coordinator

Sawyer County Health & Human Services

Sawyer County Courthouse

10610 Main, Suite 224

Hayward, WI 54843

By Fax: 715-634-5387 Attn: Shawna White, Resolution Coordinator

In person: Return this form to your local county office.