Free Authorization for Recoupment Caretaker Supplement - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22565 (07/2008)

STATE OF WISCONSIN

AUTHORIZATION FOR RECOUPMENT CARETAKER SUPPLEMENT (CTS)
Instructions: Complete and fax to 608-221-0991 (EDS). Completion of this form is required under the provisions of Section 49.775 of the Wisconsin Statutes. Failure to comply may result in a denial of recoupment. Personally identifiable information on this form will only be used to obtain relevant data required. *The provision of your Social Security Number is mandatory under Wisconsin Statutes. Your Social Security Number will be used to verify whether you receive SSI and to make certain that your SSI Caretaker Supplement benefits are paid to the correct person. If you do not provide your Social Security Number, your SSI Caretaker Supplement benefits will be denied. ES Worker Name Caretaker Name Caretaker CARES Case Number FAX Number Telephone Number

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Caretaker Social Security Number* Total Recoupment Dollar Amount

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Date the Caretaker Supplement Overpayment was discovered by the ES Worker (mm/dd/yyyy)

Itemized Recoupment by Month
Month / Year Amount Reason

Date - Case Comments on CARES (Authorizations without comments on CARES will be returned.) (mm/dd/yyyy) SIGNATURE - ES Worker

Date - Notice of Recoupment Faxed to EDS (mm/dd/yyyy) Date Signed (mm/dd/yyyy)

SIGNATURE ­ Supervisor

Date Signed (mm/dd/yyyy)

For EDS Use Only Date Keyed ___________________ Date Returned _________________