Free Unprocessed Family Care, Pace or Partnership Disenrollment Request, F-00009 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00009 (12/08)

CIP

UNPROCESSED FAMILY CARE, PACE OR PARTNERSHIP DISENROLLMENT REQUEST
The attached disenrollment request is being returned to the MCO, unprocessed for the following reason: Member Request The disenrollment requested for this reason must be submitted by the ADRC.

Loss of Contact MCO cannot Assure Member's health or safety Member has jeopardized the health or safety of others The disenrollment request for these reasons must be approved by the Office of Family care expansion.

SIGNATURE ­ IM Worker

Date Signed

Telephone Number

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