Free BadgerCare Plus Change Report, HCF 10183H - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 10183H (01/08)

CHG

BADGERCARE PLUS DAIM NTAWV QHIA TXOG COV KEV PAUV
BADGERCARE PLUS CHANGE REPORT
Koj yuav tsum hais qhia tsis pub dhau 10 hnub yog hais tias: · Koj tsiv mus rau qhov chaw tshiab los yog tawm hauv xeev mus lawm, · Muaj neeg tsiv los nyob los yog tawm hauv koj lub tsev, muaj tus cev xeeb tub los yog yug me nyuam tshiab, los yog · Koj kev nyob pauv lawm (xws li: koj mus nyob rau hauv tsev tu neeg laus/mob los yog lwm hom tsev). Koj yuav tsum hais qhia tsis pub dhau hnub tim 10 lub hlis tom ntej yog muaj kev pauv ntawm koj qhov nyiaj tau los uas lub nyiaj hli tau los ntawd ntau tshaj qhov uas kev pab cuam tau teev tseg. Yog koj muaj npe zwm rau hauv BadgerCare Plus lawm, koj yuav tau txais ntawv ceeb toom txog qhov kev pab cuam rau koj tsev neeg seb muaj li cas. Koj yuav tsum saib ntsoov koj daim ntawv ceeb toom uas tuaj tshiab. BadgerCare Plus Cov Kev Pab Nrog Npaj Lub Neej (BadgerCare Plus Family Planning Services) Yog koj zwm rau hauv BadgerCare Plus cov kev pab nrog npaj lub neej, koj tsuas hais tuaj qhia tsis pub dhau 10 hnub txog cov kev pauv li nram qab no xwb: · Koj tsiv mus rau qhov chaw tshiab los yog tawm hauv xeev mus lawm, los yog · Koj kev nyob pauv lawm (xws li: koj mus nyob rau hauv tsev tu neeg laus/mob los yog lwm hom tsev lawm.) Koj yuav hais tuaj qhia txog tej kev pauv uas yog siv daim ntawv no, hu mus rau county los yog tribal qhov chaw ua hauj lwm los yog hauv internet ntawm access.wi.gov. Yog koj siv daim ntawv no, thaum koj ua tiav thiab kos npe lawm, muab xav mus rau lub chaw ua hauj lwm hauv koj lub nroog. Mus saib phab 2, kom tau qhov chaw nyob thiab tus xov tooj ntawm lub chaw ua hauj lwm, hu rau 1-800362-3002 los yog mus rau ntawm badgercareplus.org. Yog daim ntawv no tsis txaus teev ib qho kev pauv twg, muab ib daim los sau ntxiv thiab muab tom nrog daim no xa tuaj. Koj Lub Npe (Your Name) Tus Case Nab Npawb/Social Security Nab Npawb Tus Neeg Lis Koj Cov Ntaub Ntawv Lub Npe (Worker Name)

PAUV CHAW NYOB (CHANGE IN ADDRESS)
Siv qhov chaw nram qab no los qhia koj qhov chaw nyob tshiab. Chaw nyob tshiab Lub Zos Lub Xeev Zip Code

Tus xov tooj tshiab

Hnub uas pauv

PAUV HAUV TSEV NEEG (CHANGE IN HOUSEHOLD)
Siv qhov chaw nram qab no los qhia seb muaj neeg tsiv los nyob los yog tawm hauv koj tsev lawm, yog muaj tus yuav txiv/poj niam, cev xeeb tub los yog yug me nyuam tshiab (qhia tus neeg uas yug me nyuam thiab tus me nyuam.) Lub/Cov Npe (lub xeem, npe, thawj tus ntawv ntawm lub npe nruab nrab) Hnub uas pauv

Tus Social Security Nab Npawb

Txheeb koj li cas

Hnub Yug

Piav txog qhov pauv

BADGERCARE PLUS DAIM NTAWV QHIA TXOG COV KEV PAUV HCF 10183H (01/08)

CHG

PAUV COV NYIAJ TAU LOS (CHANGE IN INCOME)
Siv qhov chaw nram qab no los qhia qhov pauv ntawm cov nyiaj tau los tas nrho ua ntej txiav se tawm, nyiaj tau los tshiab los qhov twg los, pauv kev ua hauj lwm (part-time mus rau full-time los yog full-time mus rau part-time, poob hauj lwm), pauv ntawm lub nyiaj xyoo los yog qhov tau raws xuab moos, pauv ntawm cov nyiaj Social Security, nyiaj ua tub rog, nyiaj poob hauj lwm (Unemployment Insurance), nyiaj raug mob (Worker's Compensation), los yog lwm yam kev pauv ntawm koj tsev neeg cov nyiaj tau los. Lub Npe (lub xeem, npe, thawj tus ntawv ntawm lub npe nruab nrab) Hnub cov nyiaj pauv

Yog nyiaj los qhov twg los

Qhov nyiaj tau txhua hli

Them tuab li cas (How often paid)

Hauj Lwm Tshiab (New Job) Yog txoj hauj lwm no yog hauj lwm tshiab, qhov chaw ua hauj lwm lub npe, chaw nyob thiab tus xov tooj yog li cas?

Koj ua hauj lwm pes tsawg xuab moos hauv ib lub lis piam?

Ib xuab moos tau li cas?

Poob Hauj Lwm (Loss of Job) Lub Npe (lub xeem, npe, thawj tus ntawv ntawm lub npe nruab nrab) Qhov chaw ua hauj lwm lub npe Hnub lav daim check kawg Hnub kawg (Date ended)

Daim check kawg tau li cas? $

LWM YAM KEV PAUV (OTHER CHANGES)
Siv qhov chaw no los teev lwm yam kev pauv uas koj xav hais qhia paub.

KOS NPE (SIGNATURE)
Kuv to taub tias nws muaj txim rau kev zais lus los yog muab lus tsis yog. Kuv tseem to taub tias kuv yuav tau them nyiaj rov qab rau tej kev pab cuam uas kuv tau txais vim kuv tsis qhia kom tas nrho tej kev pauv ntawm kuv. Kuv pom zoo muab pov thawj txog tej kev pauv, yog hais kom kuv muab. Kuv cov lus teb rau daim ntawv thov no yeej muaj tseeb thiab txhij txhua raws li qhov kuv paub tseeb. KOS NPE (SIGNATURE) ­ Tus Thov Kev Pab Hnub Kos Npe

Lub County los yog Tribal Qhov Chaw Ua Hauj Lwm Chaw Nyob thiab Tus Xov Tooj

RESET FORM

Phab 2