Navigating the healthcare system can be daunting, especially when it comes to voicing concerns about care received in hospice settings. The F 62287 form, issued by the Wisconsin Department of Health Services, serves as a critical tool for patients, families, and their representatives to report issues directly to the state's Division of Quality Assurance. This document outlines the process for filing a complaint, emphasizing that completion is voluntary but instrumental in ensuring concerns are investigated and addressed. It clearly states that personal information shared will be used solely for the complaint process. Moreover, the form also details patients' rights under Chapters DHS 131.21(4)(b) and (c) and DHS 131.22(2)(b) and (c), reinforcing the availability of a toll-free hotline for complaints and questions, and the support of patient advocacy services by the Board on Aging and Long Term Care. Through clear instructions and the provision of essential contact information, the F 62287 form exemplifies the state's commitment to upholding the standards of hospice care and ensuring grievances can be aired and resolved, showcasing the structures in place to support individuals and families during challenging times.
| Question | Answer |
|---|---|
| Form Name | Form F 62287 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | F62287 wisconsin hospice complaint form |
DEPARTMENT OF HEALTH SERVICES |
STATE OF WISCONSIN |
Division of Quality Assurance |
Chapters DHS 131.21(4)(b) and (c) and |
DHS 131.22(2)(b) and (c), Wis. Admin. Code |
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HOSPICE COMPLAINT REPORT
▪Completion of this form is voluntary.
▪Personal information provided on this form will be used to investigate the complaint, to communicate with the complainant, and will be used for no other purpose.
▪Additional copies of this form can be obtained from the Department web site at: http://dhs.wisconsin.gov/forms/DQAnum.asp
▪Information regarding complaint rights and procedures are located on page 2 (reverse side) of this form.
To assist in reviewing your concern, provide the following information:
1.HOSPICE INFORMATION
Name – Hospice
Street Address
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Zip Code |
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2. COMPLAINANT INFORMATION
Name – Complainant |
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Telephone Number |
Relationship to Patient |
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Street Address or P.O. Box |
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City |
State |
Zip Code |
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Date Complaint Submitted |
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Do you wish to remain anonymous? |
Yes |
No |
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3. PATIENT INFORMATION
Same as above (If the complainant and patient are not the same person, provide patient information)
Name – Patient
Telephone Number
Street Address or P.O. Box
City
State
Zip Code
4. DESCRIPTION OF CONCERN
Describe the situation or incident, the names, dates, and what happened. Write clearly and be as specific as possible. Attach additional pages, if necessary.
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HOSPICE PATIENT RIGHTS AND PROCEDURES
Chapter 50.95 of the Wisconsin State Statutes authorizes the Department of Health Services to establish rules governing the operation of a hospice.
Chapter DHS 131.21(4)(b) and (c) of the Wisconsin Administrative Code, authorized by the above state statute, describes a hospice patient’s right to file a complaint with the Department as follows:
(b)Express complaints to the Department, and to be given a statement provided by the Department setting forth the right to and procedure for filing verbal or written complaints with the Department; and
(c)Be advised of the availability of a
Chapter DHS 131.22(2)(b) and (c) of the Wisconsin Administrative Code, authorized by the above state statute, describes a hospice family member’s right to file a complaint with the Department as follows:
(b)Express complaints to the Department and be given a statement provided by the Department, setting forth the right to and procedure for filing verbal or written complaints with the Department; and
(c)Be advised of the availability of a
The above statute and rules mean that:
(1)You have a right to complain directly to the Department of Health Services.
(2)The hospice that serves you must advise you of your right to file a complaint with the Department of Health Services; they must also explain the complaint filing process.
(3)The hospice that serves you must advise you of your right to receive patient advocacy services from the Board on Aging and Long Term Care (BALTC).
Services from the BALTC include:
▪Investigation of complaints
▪Mediation to resolve problems or disputes relating to long term care patients
▪Provision of information and counseling related to available insurance policies that supplement federal Medicare coverage
The BALTC may be contacted by calling its
Copies of this complaint form and these requirements should be provided by the hospice to each patient or patient representative (1) prior to provision of any services and (2) at the conclusion of the service agreement.
If a patient or a patient representative (anyone representing the patient’s interests) has a concern with the patient’s care and treatment, believes that the patient’s rights have been violated, and/or that the hospice has not resolved these concerns, a complaint may be filed using any of the following methods.
▪Writing to: Department of Health Services
Division of Quality Assurance / Bureau of Health Services
ATTN: Hospice Complaint Coordinator
P.O. Box 2969
Madison, WI
▪Calling:
▪Completing an
▪If you have Medicare coverage, you may also make complaints by writing to or calling:
Metastar
2909 Landmark Place
Madison, WI 53713
*The