Letter to Parents - Autism Funding Attachment

Restriction of Patient Health Information

Regarding Medicaid Autism Services

To assist transitioning to the waiver alternative, we will forward your child's name, your name, and address to your county agency. If you do not want this information to be forwarded, please complete and send this form to the address listed below by July 15, 2003. By sending this form, you are stating that you DO NOT wish to have your child receive continued in-home autism services that will be provided under the waiver alternative beginning in the fall.

PDF (28 KB)

Mail this form by July 15, 2003, to:

Alan White
Bureau of Program Integrity
P. O. Box 309
1 W. Wilson Street
Madison, WI 53701-0309

CH06026.CW

Last Revised: November 12, 2014