2024 Aging & Disability Resource Center of Eau Claire County-Complaint or Grievance

Submitting this form requests an Internal Review with the ADRC Director.

Requests for External Reviews can be submitted to: Wisconsin Dept of Health Services, Office for Resource Center, ADRC Specialist Grievances, 1 W. Wilson St, PO Box 2659, Madison, WI 53701-2659

Question Title

* 1. Information:

Name

Address

City/Town

Phone Number

Question Title

* 2. Have you asked someone outside of the Aging & Disability Resource Center to help you with filing and resolving the complaint or grievance?

Yes

No

Question Title

* 3. If Yes, Please indicate who assisted you?

Name

Address

City/Town

Phone Number

Question Title

* 4. Please describe your complaint or grievance about ADRC services:

Question Title

* 5. Requested remedy (what are your ideas on how you would like this issue resolved?):