Free QUEST Card and PIN Responsibility Statement, HCF 16007 - Wisconsin


File Size: 25.0 kB
Pages: 1
Date: October 26, 2005
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHFS
Word Count: 223 Words, 1,332 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F16007.pdf

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Preview QUEST Card and PIN Responsibility Statement, HCF 16007
STATE OF WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 16007 (Rev. 10/05)

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QUEST CARD AND PIN RESPONSIBILITY STATEMENT
Personally identifiable information will be used only for the direct administration of FoodShare Wisconsin.

By checking the boxes below I certify that, based on the training I have received on the use of my Wisconsin QUEST card and Personal Identification Number (PIN), I understand that:

I am responsible for safeguarding my QUEST card and PIN.

Any FoodShare account transaction made by myself, an Authorized Buyer, Alternate Payee or by any other person to whom I voluntarily give my QUEST card and PIN is considered authorized and the benefits will not be replaced.

I must report a lost or stolen card immediately to the toll free Customer Service Hotline at 1-877-415-5164 (TTY: 1-800-947-3529).

I know that if my card is lost or stolen, my FoodShare benefits will not be replaced for the time period between the loss or theft of my QUEST card and the time I report the loss or theft to the Customer Service Hotline.

I may be disqualified, lose FoodShare benefits from FoodShare Wisconsin, or risk monetary fines and/or imprisonment for fraudulent or illegal use of my QUEST card.

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