Free Wisconsin Birth to 3 Program - Request for a Hearing - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22433 (08/2008)

STATE OF WISCONSIN

REQUEST FOR A HEARING
Wisconsin Birth to 3 Program
This form has been developed to assist parents in requesting a hearing in writing. Use of this Request for a Hearing form is voluntary. However, using this form assures that the required written information is received and that the hearing occurs in a timely manner. Instructions: Complete two copies of this form. Provide all the information requested. Send one copy to the address below and keep one copy for your records. You will be contacted by DHS regarding your hearing request. Name ­ Child (Last, First, MI) * Name ­ Party Requesting Hearing * Address of Requesting Party * County Responsible for Early Intervention Services Relationship to the Child Telephone Number ­ Daytime *

* This confidential information is required to arrange for the hearing and will only be used for that purpose. Any information given during the hearing process is confidential unless the parent requests that the hearing be open to the public. State the specific reasons for requesting a hearing. Include a description of the nature of the dispute, including facts relating to the problem. (Use additional sheets or back if necessary.)

Propose a resolution of the problem, to the extent known at this time. (Use additional sheets or back if necessary.)

SIGNATURE ­ Party Requesting the Hearing

Date Signed

For additional information, contact the Birth to 3 Program at 608-266-8276. Submit one copy of completed form to: Birth to 3 Program/Mediation PO Box 7851 Madison, WI 53707-7851

Date Received

For DHS Use ONLY Hearing Date