Free Wisconsin Funeral and Cemetery Aids Program Reimbursement Request, F-10141 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10141 (04/09)

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WISCONSIN FUNERAL AND CEMETERY AIDS PROGRAM REIMBURSEMENT REQUEST
Social Security Numbers and personally identifiable information will be used only for the direct administration of the Wisconsin Funeral and Cemetery Aids Program. This form must be completed in order to receive Wisconsin Funeral and Cemetery Aids Program reimbursement. Once this form is completed, return the form and all other required documentation to the local county/tribal human or social services agency (local agency). To find the local agency's address visit the Department of Health Services' web site at dhs.wisconsin.gov/em/imagencies/index.htm.

SECTION 1 ­ Decedent Information
Name Address Date of Birth Date of Death Date(s) of Service

Social Security Number

SECTION 2 ­ Provider Information
Funeral Home Name Address Cemetery / Crematorium Name Address

Telephone Number

Telephone Number Check type of provider

Cemetery

Crematorium

SECTION 3 ­ Total Funeral and Cemetery Expenses
Total Funeral Expenses Funeral Homes: Attach "Statement of Funeral Goods and Services Selected". If you do not include the Statement, your reimbursement request will be denied. Assure that the Statement includes total actual charges, not estimates, for each of the goods/services provided by the funeral home and any funeral home within the same corporation, whether the goods/services were provided before or after death. Enter the exact dollar amount for each good/service provided. Also, assure that the Statement includes and clearly identifies all cash advances. Cash advances will not be counted toward the total funeral expense limit under s. 49.785 Wis. Stats., if reimbursement is required in an amount no greater than that advanced. Cash advances must be verified. If you provided goods/services on behalf of the cemetery because the cemetery does not provide those goods/services (e.g. outer burial vault), indicate that on the Statement. Such goods/services will not be counted toward the total funeral expense limit. Total Cemetery Expenses Cemetery or Crematorium: Report total actual charges, not estimates, for each of the goods/services provided by the cemetery or crematorium, whether the goods/services were provided before or after death. Enter the exact dollar amount for each good/service provided. If you list an amount for "Services associated with supplying or delivering these goods", describe these services. If the service is not listed, enter the total under "Other cemetery expenses" and describe the services provided. $ $ $ $ $ $ Monument, marker, nameplate Cemetery lot, mausoleum space, vase or urn Opening/closing of grave or mausoleum space Cremation Services associated with supplying or delivering these goods (describe below) Other cemetery expenses (describe below)

WISCONSIN FUNERAL AND CEMETERY AID PROGRAM REIMBURSEMENT REQUEST Page 2 F-10141 (04/09)

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SECTION 4 ­ Reimbursement Request
NOTE: The total charges minus any amounts paid by the estate and others, equals the "Reimbursement Request". Reimbursement under s. 49.785 Wis. Stats. is available only when the estate of the decedent is insufficient to pay for his/her funeral, burial and cemetery expenses. By signing below, the Provider certifies that: 1) the charges indicated here represent total actual charges for goods/services provided by the Provider, and 2) funds to which the Provider is entitled as the beneficiary of a pre-arranged burial agreement are included in the "Paid by Estate/Other" amounts. By signing below, the Executor or Family Representative, certifies that the "Paid by Estate/Other" amounts indicated here represent the total funds available from the estate and other funding sources to cover funeral, burial and cemetery expenses of the decedent. Total Funeral Charge Amount Paid by Estate or Other Reimbursement Request $ - $ =$ Total Cemetery Charge Amount Paid by Estate or Other Reimbursement Request $ - $ =$

Special Circumstances. If there are special circumstances that may justify exceeding the total expense limit, or the reimbursement limits under s. 49.785 Wis. Stats., describe those circumstances in detail on an attachment to this reimbursement request.

SECTION 5 - Signatures
Provider of services and executor or family representative must sign and date below. FUNERAL HOME SIGNATURE ­ Provider SIGNATURE ­ Executor / Family Representative Address ­ Executor / Family Representative Date Signed Date Signed Telephone Number

CEMETERY / CREMATORIUM SIGNATURE ­ Provider SIGNATURE ­ Executor / Family Representative Address ­ Executor / Family Representative Date Signed Date Signed Telephone Number

SECTION 6 ­ Reimbursement Authorization
Date received

(Office Use Only)

Worker Name Yes No If "Yes", allowable category Other qualifying individual? Yes No . Cemetery $ . Yes No Approved by DHFS? Yes No Date .

Medicaid/BadgerCare Plus member at time of death? W-2 paid placement at time of death? Yes No

If "Yes", specify type of other qualifying individual Authorized reimbursement: Funeral $ If not authorized, explain Special circumstances?

Reimbursement authorized by