Free Summary of Information Form Letter, F-00098 - Wisconsin


File Size: 223.3 kB
Pages: 1
Date: June 24, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BEM
Word Count: 170 Words, 1,053 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/f0/f00098.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00098 (06/09)

STATE OF WISCONSIN

Date:

TO:

RE: SUMMARY OF INFORMATION Enclosed is a summary of the information you gave us when you applied for benefits. The summary includes information about your rights and responsibilities as well as program rules. The ForwardHealth Enrollment and Benefits handbook, with more information, will be mailed to you. Please read this information carefully. If any information, on the enclosed summary is wrong, you must contact us at the telephone number listed below. If all information is correct, please sign and return the enclosed Signature Page to the address below by . Your benefits can not be approved until we receive the signed Signature Page. If we need proof of your answers, a separate letter will be mailed to you. If you have questions, please visit access.wi.gov or call the number below. If you have a disability and need help with this information, please call the number below.

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