Response

Medicare
Privacy Release and Constituent Information Form

Contact Information

Preferred Prefix

First Name

Middle Name or Initial

Last Name

Suffix

Street Address

Street Address (2)

City

State

Zip

Verify Email

Phone

Alternate Phone

Date of Birth

Social Security #

Case Details

Which government agency (or agencies) have you been working with?

Claim Number (if available)

Have you contacted another Congressional office?

Which Congressional office?

When did you last contact that office?

Is this matter pending before a court of law?

Your Request

What do you need help with?(describe the issue in as much detail as necessary)

Is there anything else that Senator Baldwin or her staff needs to know?

Submit and Generate Privacy Release Form

Once you have reviewed your information above, please date, sign, and press the Submit button below to load the confirmation page. This will load a screen where you can verify that your information is correct and make any changes if necessary before submitting a final draft.

Today's Date

Sign using your mouse or finger...