How to Make a Request
- Respond to ALL questions marked by an asterisk (*) unless instructed otherwise.
- Give complete information to ensure a clear understanding of the request.
Submitting the Request Form:
- Review the information that you have entered, then click the "Submit" button when prompted.
- If you exit before selecting the "Submit" button, all information you have entered will be lost. Any notifications being sent by the system will be canceled.
- After clicking the "Submit" button, wait for a confirmation page with your confirmation number. Your request has not been accepted until you see the confirmation page.
- Print the confirmation page or write down the confirmation number. Your confirmation number will be used to reference your request.
- A Customer Service Representative will contact you to discuss your concern in detail.
- Privacy: The information provided to MDCR in your request for services is confidential and will be used only by public officials performing their duties.
- FOIA: The information you provide to MDCR in your request for program services is subject to the Freedom of Information Act (FOIA).
- If you do not hear from us within three business days, please call our Intake Unit at 800-482-3604 to protect the timeliness of your filing rights.