How to Make a Request

Answering Questions:

  • 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.

 Additional Notes:

  • 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.