Please verify that your name, email address, mailing address, and telephone number are typed correctly on the request below so we can contact you with any questions.
It would also be helpful if you would include as much information as possible relating to your request so we can respond promptly and accurately. This information can include:
- The full name of the person for whom you are asking help (if different than your own), and your relationship to the individual.
- That person's date of birth, county of residence and how to contact them by phone.
- Medicaid ID number(s) (if applicable).
- The name of the provider and/or facility about which you are writing.
- The address of that provider/facility.
- The type of provider/facility (example: assisted living facility, hospital, nursing home).
- Other information you feel would help us respond fully to your concerns.