Free Wisconsin Hemophila Home Care Program Residency Verification, F1145 - Wisconsin

DEPARTMENT OF HEALTH SERVICES DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY F-1145 (02/09)

STATE OF WISCONSIN ss. 49.685 WIS STATS

WISCONSIN HEMOPHILIA HOME CARE PROGRAM RESIDENCY VERIFICATION
Wisconsin Chronic Disease Program (WCDP) requires the information requested in this form to enable WCDP to determine member eligibility, if the member is unable to provide a copy of either of the following documents: · · A copy of their most recent rental agreement OR property tax bill. A copy of their Wisconsin drivers license with current address OR state identification with current address OR Student ID (only for applicants under age 19).

The use of this form is mandatory, if the member is unable to supply the requested documents listed above. Failure to supply the information requested on this form may result in a denial of WCDP eligibility. Provision of your social security number is voluntary, however, your social security number is one of the unique identifiers used to identify you as a unique person in our claim system. Personally identifiable information is confidential and is used for purposes directly related to WCDP administration.

SOCIAL WORKER INFORMATION 1. Name - Social Worker

2. Telephone - Social Worker

3. Facility Name

4. Facility Street Address

5. City, State, ZIP Code

MEMBER INFORMATION 6. Name - Applicant

7. Social Security Number (SSN) or WCDP Identification Card Number

Wisconsin Administrative Code 153.03(1) specifies in order to be eligible for the Adult Cystic Fibrosis Program the applicant must be a resident of Wisconsin. Based on my knowledge, I attest that_______________________________________________ is a resident of Wisconsin. I have verified that his home address is in Wisconsin.

By signing this form I am attesting the member is a Wisconsin resident as set forth in HFS 153.02(17). SIGNATURE - Social Worker Date Signed