Form Letter: DHS Ch. 94 Patient/Client Rights Grievance
Form letter that people with disabilities can use to write a Patient Rights Grievance under WI Dept. of Health Services Administrative Code, Ch. 94.
About this form letter
You may use this letter to write a Patients Rights Grievance under Wisconsin Department of Health Services Administrative Code, Chapter 94 (DHS 94).
How to use this form letter
You can type your information into this form letter using a computer and print it out. If you don’t have a computer or can’t use one, you can print the form letter and fill it out by hand.
Once you have filled out the letter, you can send it to the Client Rights Specialist (CRS). Keep a copy of the letter for yourself. You can write down when you sent your letter and when you are expecting a reply.
This form letter shows what can be in a grievance letter. It is not legal advice. For legal advice specific to your situation, please talk with an attorney.
[Date]
RE: Patient Rights Grievance
Patient name: [Your name]
Dear Client Rights Specialist,
My name is [your name]. This letter is my formal grievance.
I get services for mental illness / developmental disability / alcohol or substance abuse from [Name] agency.
My client/patient rights were violated when: [describe what happened].
This violated my right(s) to: [write which rights you believe were violated].
To fix this problem, I’m asking for: [write the solution you are asking for].
I have good cause to file late because (fill out if this applies, cross out if not): [explain the reason you are filing late].
I look forward to your timely, written response.
Sincerely,
[Your name]
Phone: [Your phone number]
Email: [Your email address]
