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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