Free Designation of Essential Person, HCF 10186 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10186 (07/08)

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DESIGNATION OF A BADGERCARE PLUS ESSENTIAL PERSON
Certain individuals, who would not otherwise be included in a group's BC+ coverage, may be included if the individual meets the definition of an essential person under BadgerCare Plus policy. This form must be completed to designate an individual as an essential person for BadgerCare Plus. Documentation must be provided that the essential person is capable of and does provide the essential benefit or service. Name - Essential Person Essential person's relationship to person receiving the benefit

Check below for the essential benefit or service that the selected essential person will perform and write in the name of the recipient of the service or benefit. Child care that enables full time (30 hours or more a week) for pay. Child care that enables (30 hours or more a week). Child care that enables GED classes full time (as defined by the school). Or Care for a disabled family member in the BadgerCare Plus group. I understand that the disability must be medically verified. The disabled person who requires the care is . to work outside the home, to receive training full time to attend high school or

Your signature on this form indicates that: The essential person listed on this form is essential to your well being or the well being of other persons in your family and you request that s/he be included in your BadgerCare Plus group as an essential person. The essential person is capable of providing the essential benefit or service you are requesting. You understand that you may be asked to provide information to prove that the person selected is capable of providing the essential benefit or service. You understand the county or tribal agency must approve or deny your request that an essential person be included in your BadgerCare Plus group.

SIGNATURE­ Applicant or Authorized Representative

Date Signed

Agency Decision

SIGNATURE - Agency Worker

Case Number

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