Form F 62287 PDF Details

Are you a US Citizen who has lived in a foreign country for at least 330 days during the past 12 months? If so, you may be able to file Form F 62287 to claim exemption from US tax on your worldwide income. In this blog post, we will discuss who is eligible to file Form F 62287 and what requirements must be met in order to do so. We will also provide step-by-step instructions on how to complete the form. So, if you are wondering whether or not you can claim exemption from US tax on your worldwide income, keep reading!

QuestionAnswer
Form NameForm F 62287
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesF62287 wisconsin hospice complaint form

Form Preview Example

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Quality Assurance

Chapters DHS 131.21(4)(b) and (c) and

F-62287 (Rev. 08/09)

DHS 131.22(2)(b) and (c), Wis. Admin. Code

 

Page 1 of 2

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

City

State

Zip Code

 

 

2. COMPLAINANT INFORMATION

Name – Complainant

 

 

 

Telephone Number

Relationship to Patient

 

 

 

 

 

 

 

Street Address or P.O. Box

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Date Complaint Submitted

Do you wish to remain anonymous?

Yes

No

 

 

 

 

 

 

 

 

 

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.

F-62287 (Rev. 08/09)

Page 2 of 2

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 toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under Chapter 16.009, Wis. Stats.

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 toll-free hotline, including its telephone number, to receive complaints or questions about local hospices, and be advised of the availability of the long term care ombudsman to provide patient advocacy and other services under Chapter 16.009, Wis. Stats.

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 toll-free number at 1-800-815-0015.

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 53701-2969

Calling: Toll-free Wisconsin Home Health / Hospice Hotline – 1-800-642-6552 *

Completing an on-line complaint form at: http://dhs.wisconsin.gov/bqaconsumer/HealthCareComplaints.htm

If you have Medicare coverage, you may also make complaints by writing to or calling:

Metastar

2909 Landmark Place

Madison, WI 53713

1-800-362-2320

*The toll-free hotline operates a voice message system 24 hours a day. Calls received during the evenings, on weekends, or on holidays are returned the next day. The purpose of the hotline is to receive complaints regarding Wisconsin licensed and Medicare/Medicaid certified home health agencies and hospices and to provide information about Wisconsin home health agencies and hospices.