Free Wisconsin Funeral and Cemetery Aids Program Reimbursement Request Instructions, hcf 10141A - Wisconsin

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

STATE OF WISCONSIN

WISCONSIN FUNERAL AND CEMETERY AIDS PROGRAM REIMBURSEMENT REQUEST INSTRUCTIONS
The Wisconsin Funeral and Cemetery Aids Program Reimbursement Request form must be completed and signed to receive reimbursement. Once this form is completed and signed, return the form and all other required documentation to the local county or tribal 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
Enter the decedent's full name, address, social security number, date of birth and date of death. Enter the date(s) that services were provided.

Section 2 ­ Provider Information
Funeral Home: Enter the name, address and telephone number of the funeral home in the space designated for funeral homes. Cemetery/Crematorium: Enter the cemetery or crematorium name, address and telephone number and check the box that describes the type of service provider, either "Cemetery" or "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. Failure to do so may result in those goods/services being counted as funeral expenses. 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.

Section 4 ­ Reimbursement Request
Reimbursement Request is the total charges minus any amount paid by the estate and others. 1. Funeral Expenses-- Indicate the total actual charges for all funeral goods and services reported in Section 3. Do not include cash advance items, if the funeral home requires reimbursement in an amount no greater than that advanced. Do not include services that are required, but not provided by the cemetery (e.g. outer burial vault). Indicate the amount paid by the estate and others toward the total funeral charges. Be sure to include all funds to which the funeral home is entitled as the beneficiary of a pre-arranged burial agreement. Subtract the amount paid by the estate and others from the total funeral charges to determine the reimbursement request. Cemetery Expenses-- Indicate the total actual charges for all cemetery goods and services reported in Section 3, including any cemetery goods and service cash advanced by the funeral home or provided by the funeral home on behalf of the cemetery (e.g. outer burial vault). Indicate the amount paid by the estate and others toward the total cemetery charges. Be sure to include all funds to which the cemetery or crematorium is entitled as the beneficiary of a pre-arranged agreement. Subtract the amount paid by the estate and others from the total cemetery charges to determine the 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 the reimbursement request.

2.

3.

Section 5 ­ Signatures
Funeral Home - Service provider(s) and executor or family representative must sign and date the form. Enter the address and telephone number for the executor or family representative that signs the form. Cemetery/Crematorium - Service provider(s) and executor or family representative must sign and date the form. Enter the address and telephone number for the executor or family representative that signs the form.

Section 6 ­ Reimbursement Authorization (Office Use Only)
Do not write in this area. This area is to be completed by the local agency.