Free BadgerCare Plus Premium Employer Wage Withholding, HCF 13025 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 13025A (02/08)

STATE OF WISCONSIN

BADGERCARE PLUS PREMIUM

EMPLOYER WAGE WITHHOLDING COMPLETION INSTRUCTIONS
BadgerCare Plus requires certain information to authorize and pay for medical services provided to enrolled members. Members are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information shall include, but is not limited to, information concerning enrollment status, accurate name, address, and identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about applicants and members is confidential and is used for purposes directly related to the program administration such as payment of premiums by members. Failure to supply the information requested by the form may result in denial of payment for services. INSTRUCTIONS BadgerCare Plus Members The employer should fill out this form for the BadgerCare Plus premium payment to be taken out of the paycheck. If this option is chosen, fill in the BadgerCare Plus Case Number found on the BadgerCare Plus premium notice. Give the Employer Wage Withholding Form, along with the Member/Employer Electronic Funds Transfer form, HCF 13026, to the employer. The employer may also call 1-888-907-4455 to request that the forms be mailed to them. Employer Instructions for Completing This Form Fill out the employee's last and first name, Social Security Number, and monthly BadgerCare Plus premium amount. BadgerCare Plus premiums may be paid either by EFT or by direct payment. · Electronic Funds Transfer If the employer chooses to pay by EFT, complete the Member/Employer Electronic Funds Transfer form. Send the form to the address listed at the bottom of the EFT form. BadgerCare Plus will then take the entire premium amount out of the checking account once per month. The form can also be faxed to 1-608-251-1513. · Direct Payment Employers will receive a premium notice each month if they choose to make a direct payment each month. Send the payment with the premium notice and completed Employer Wage Withholding form to the following address: BadgerCare Plus Department of Health and Family Services PO Box 93187 Milwaukee WI 53293-0187 Then send the completed Employer Wage Withholding form to the following address: BadgerCare Plus Cash/Premium Unit PO Box 6648 Madison WI 53716-0648 · Employer Information Enter the employer's name and address.

If there any questions regarding the above information, call 1-888-907-4455.

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 13025 (02/08)

STATE OF WISCONSIN

BADGERCARE PLUS PREMIUM

EMPLOYER WAGE WITHHOLDING
Instructions: Type or print clearly. Before completing this form, read the Employer Wage Withholding Completion Instructions, HCF 13025A. Complete this form for the employee (and Electronic Funds Transfer [EFT] form, if applicable). If there are any questions, call 1-888-907-4455. Employee Information Name -- Employee (Last, First, Middle Initial) Case Head Identification Number

Social Security Number -- Employee

Monthly Premium Amount

Electronic Funds Transfer To pay the premium via monthly EFT, complete the Member / Employer Electronic Funds Transfer form, HCF 13026. The form can be faxed to 1-608-221-8185.

Direct Payment To pay the premium via direct payment, send the payment, payable to BadgerCare Plus, and this completed form to the address listed below. Do not send cash. Employer Information Name -- Employer Telephone Number -- Employer

Address -- Employer (Street, City, State, ZIP Code)

SIGNATURE -- Employer

Date Signed

DISTRIBUTION

Mail completed form along with direct payment to the following address: BadgerCare Plus Department of Health and Family Services PO Box 93187 Milwaukee WI 53293-0187

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