Free ForwardHealth Provider Suggestion, F-1016 - Wisconsin


File Size: 11.8 kB
Pages: 1
Date: March 20, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BBM
Word Count: 157 Words, 1,035 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F0/F01016.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1016 (02/09)

STATE OF WISCONSIN

FORWARDHEALTH

PROVIDER SUGGESTION
The Division of Health Care Access and Accountability is interested in improving its program for providers and members. Providers who feel any policy or procedure stated in provider publications should be revised or who wish to suggest new policies are encouraged to submit recommendations. Providers may attach additional pages if needed. Send the completed form to the following address: Division of Health Care Access and Accountability Bureau of Benefits Management PO Box 309 Madison WI 53701-0309 The use of this form is voluntary and providers may develop their own form as long as it includes all the information on this form. SECTION I -- PROVIDER INFORMATION Name -- Provider Provider Number

Address -- Provider

Suggestion

SECTION II -- PUBLICATION INFORMATION (IF APPLICABLE) Title, Number, and Date Published -- Publication

Question / Problem

Suggestion

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