DEPARTMENT OF HEALTH SERVICES
Office of Legal Counsel
F-80983A (04/2024)
STATE OF WISCONSIN
INSTRUCTIONS
CIVIL RIGHTS COMPLAINT
Federal civil rights laws prohibit discrimination of members, applicants, enrollees, and beneficiaries in any Wisconsin
Department of Health Services (DHS) program or activity that receives federal financial assistance and that is run by DHS
directly or by its partners, contractors and grantees. Those laws include, for example, Section 1557 of the Patient
Protection and Affordable Care Act of 2010, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of
1973, the Americans with Disabilities Act of 1990, and the Age Discrimination Act of 1975, and prohibit recipients and sub-
recipients of federal financial assistance from discriminating on the basis of race, color, national origin, sex (including
gender identity and sexual orientation), age, disability, and, in some programs, religious creed or political beliefs, in their
programs or activities, and retaliating against an individual for opposing discrimination. If you were wrongfully denied
services, or if the treatment you received was separate or different than others received, or if the program was not
accessible to you, and you believe this was because of one or more of those protected bases, it may be discrimination.
The precise nondiscrimination requirements depend on which federal agency (for example, the United States Department
of Health and Human Services (HHS) or the United States Department of Agriculture (USDA)) funds the program or
activity.
For HHS programs (for example, Medicaid/BadgerCare), you may file a discrimination complaint with the entity (for
example, the doctor’s office, the pharmacy, the hospital) that you believe discriminated against you, or you may file a
discrimination complaint with DHS. Additionally, you may file a civil rights complaint with HHS, the federal agency, directly.
See contact information below.
For the USDA program Supplemental Nutrition Assistance Program (SNAP)/FoodShare Wisconsin, you may file a
discrimination complaint with DHS. Additionally, you may file a civil rights complaint with USDA, the federal agency,
directly. See contact information below.
For all other USDA programs, such as Women, Infants and Children (WIC), The Emergency Food Assistance Program
(TEFAP), the Commodity Supplemental Food Program (CSFP), or other non-SNAP USDA programs discrimination
complaints will be handled by the USDA. Complaints arising in these programs regarding the USDA programs should be
filed directly with the USDA. See contact information below. If you file a civil rights complaint with DHS about one of
these USDA programs, it will be forwarded to USDA.
SECTION I – Who Was Discriminated or Retaliated Against?
If you believe you were discriminated against, provide the date you completed and submitted Form 80983, Civil
Rights Complaint, your name, address, telephone number and other contact information as requested. You may file
on behalf of another person if you believe that person has been discriminated against.
SECTION II –What Person or Organization Do You Believe Discriminated or Retaliated Against You (or someone
else)?
Provide the name of the agency, medical assistance provider, or other business that you believe discriminated
against you in providing benefits, services or access to a DHS program. If known, identify the name(s) of the
individual(s) who you believe discriminated against you and the agency or recipient that employs that/those
individual(s).
SECTION III – What Do You Allege is the Reason for Discrimination or Retaliation?
Identify the DHS program of which you are a member, applicant, enrollee, or beneficiary (for example, BadgerCare
Plus, Medicaid, SeniorCare, Supplemental Nutrition Assistance Program (SNAP)/FoodShare Wisconsin, Include,
Respect, I Self-Direct (IRIS), Family Care, FoodShare Employment and Training (FSET), Refugee Health Program,
or other DHS program). Check the box that you believe was the reason for the discriminatory or retaliatory action that
you experienced. Provide the last date in which the discrimination occurred.
SECTION IV – What Discriminatory or Retaliatory Action Happened To You?
Describe the events that occurred, or the action that was taken by the individual(s), agency or entity that you believe
discriminated against you. Explain as clearly as possible what happened, when it happened, why you believe it
happened, and how you were discriminated against. If applicable, please include how other persons were treated
differently than you. If you have documents or other records to support your description of the discrimination that you
are reporting, provide a copy of the supporting records.
F-80983A (04/2024)
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SECTION V – Submit Your Complaint
1. At the State Agency Level
To the Wisconsin Department of Health Services (DHS):
To file a discrimination complaint with DHS, complete the Civil Rights Complaint Form (F-80983) and mail or
email it to:
Department of Health Services
Civil Rights Compliance
1 West Wilson Street, Room 651
P.O. Box 7850
Madison, WI 53707-7850
608-267-4955 (Voice), 608-267-1434 (Fax)
711 or 1-800-947-3529 (TTY)
Email: DHSCRC@dhs.wisconsin.gov
2. At the Federal Agency Level
To the U.S. Department of Health and Human Services (HHS):
To file a discrimination complaint about any of the HHS programs or services administered by the Wisconsin
Department of Health Services, mail, email, call, or use their online OCR Complaint Portal:
Office for Civil Rights
U.S. Department of Health and Human Services
Centralized Case Management Operations
200 Independence Avenue, S.W.
Suite 509F HHH Bldg.
Washington, D.C. 20201
Email: OCRComplaints@hhs.gov, OCRmail@hhs.gov
1-800-368-1019; 1-800-537-7697 (TDD)
Online Portal: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf
To the U.S. Department of Agriculture (USDA):
USDA civil rights complaints about USDA programs other than SNAP/FoodShare Wisconsin must be filed with the
USDA; civil rights complaints about SNAP/FoodShare Wisconsin may be filed with the USDA. To file a
discrimination complaint with the USDA, mail or email:
U.S. Department of Agriculture (USDA)
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, S.W.
Washington, D.C. 20250-9410
Email: program.intake@usda.gov
(202) 260-1026 (Local)
(866) 632-9992 (Toll-free Customer Service)
(800) 877-8339 (Local or Federal relay)
(866) 377-8642 (Relay voice users)
(800) 845-6136 (Spanish)
Fax: (202) 690-7442
