Free Notice of Program Violation, HCF 16014 - Wisconsin


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State: Wisconsin
Category: Health Care
Author: DHCAA-BOC
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URL

http://dhs.wisconsin.gov/forms/F1/F16014.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES, Division of Health Care Access and Accountability DEPARTMENT OF WORKFORCE DEVELOPMENT, Division of Workforce Solutions F-16014 (07/08)

NOD
Date Notice Mailed Case Number

NOTICE OF PROGRAM VIOLATION
Name CARES PIN Address City

State

Zip Code

We believe you received Wisconsin Works (W-2) payments to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to mislead, misrepresent or withhold facts. Period in which you received W-2 payments incorrectly to . Amount of overpayment $

We believe you received Child Care Assistance to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to mislead, misrepresent or withhold facts. Period in which you received Child Care incorrectly to . Amount of overpayment $

We believe you received Medicaid/BadgerCare Plus benefits to which you were not entitled by: intentionally making a false or misleading statement; intentionally misrepresenting or withholding facts; committing an act intending to obtain benefits to which you were not entitled. Period in which you received Medicaid/BadgerCare Plus incorrectly to Amount of overpayment $ .

We believe you received (or attempted to receive) FoodShare benefits to which you were not entitled. We believe you received the overissuance by intentionally violating a FoodShare Wisconsin rule. Period in which you received FoodShare benefits incorrectly Amount of overissuance $ The specific alleged violation is to .

The following evidence supports this allegation

You must contact your W-2or local county or tribal agency within ten (10) days of the postmark on this notice's envelope to make an appointment to resolve this problem. Agency Representative Telephone ( )

Distribution:

Member original

Case file copy

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