Free Wisconsin Hemophilia Home Care Financial Need Statement Cover Memo, F-1195 - Wisconsin

DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY WISCONSIN CHRONIC DISEASE PROGRAM FINANCIAL SERVICES P O BOX 6410 MADISON WI 53716-0410

Jim Doyle Governor Karen E. Timberlake Secretary

State of Wisconsin Department of Health Services

Telephone: 800-362-3002 FAX: 608-224-6318 TTY: 866-824-3753

www.forwardhealth.wi.gov

DATE: TO:

March 25, 2009 All Wisconsin Chronic Disease Program (WCDP) Members Hemophilia Home Care (HHC) Program Wisconsin Chronic Disease Program (WCDP)

FROM:

Please complete the enclosed Financial Need Statement [F-1187 (02/09)] and return it to the Wisconsin Chronic Disease Program before May 31, 2009. Please also note that Wisconsin Medicaid has undergone a name change and is now also referred to as BadgerCare Plus. There is no longer a BadgerCare plan.

IMPORTANT: Please do NOT throw out your current ForwardHealth ID cards. You will NOT receive another card after you send in your new financial needs information. However, you must provide all information requested. We will return incomplete forms to you. If you do not return your completed Financial Need Statement, claims for services after June 30, 2009, will not be paid and your ForwardHealth card will be deactivated for WCDP coverage. Please pay particular attention to the following items. If necessary, staff at your treatment center will be able to assess your particular case and advise you in completing and mailing this form. SECTION 5. INSURANCE INFORMATION - You must provide accurate, current insurance information. If your insurance has changed, please indicate the date your old insurance terminated and your new insurance began. If you have more than one insurance policy, list the second insurance company under Insurance #2. Please attach additional sheet(s) of paper with your insurance information if needed. Incomplete insurance information may cause your claims to be rejected. SECTION 6. FINANCIAL INFORMATION. Item 18. CURRENT MONTHLY/YEARLY FAMILY INCOME - Your eligibility will be determined by current monthly or annual family income. You must report all items (a. through l.) for all your immediate family to determine your total family income. SUBMIT ADDITIONAL INFORMATION. You will need to submit the following items with the Financial Needs Statement: · Copy of last year's Wisconsin Income Tax return with all attachments. · Copy of the most recent rental agreement OR property tax bill.

Wisconsin.gov

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Copy of your Wisconsin drivers license with current address OR State identification with current address OR Student ID (only for applicants under age 19). Copy of your Alien registration card issued by the INS if you are not a U.S. citizen.

Please send your completed materials to: Wisconsin Chronic Disease Program Attention: Eligibility Unit P.O. Box 6410 Madison, WI 53716-0410 You will receive a new WCDP eligibility card after your financial information is updated. Please review your card for accuracy and report any discrepancies to the Wisconsin Chronic Disease Program. If you have questions, you may call (800) 362-3002.

F-1195 (02/09)