Free None - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Heath Care Access and Accountability F-16004H (07/08)

EBT

NTAWV TAW TUS TSO CAI SIV / TUS TSO CAI LAV RAU COV FOODSHARE NYIAJ MUAS NOJ
Social Security Numbers thiab lwm yam qhia txog tus kheej tsuas yog yuav siv rau kev tswj FoodShare Wisconsin xwb. Koj xav xaiv ib tug Tso Cai Siv (Authorized Buyer) los pab koj siv koj cov FoodShare nyiaj muas noj los tau. Ntxiv rau daim npav uas koj tau, tus tso cai siv yuav tau ib daim npav QUEST ua nws tus kheej npe, thiab yuav muaj cai rho koj cov FoodShare nyiaj muas noj los yuav zaub mov rau koj tsevneeg. los sis Koj xav xaiv ib tug Tso Cai Lav (Alternate Payee) los ua tus sawvcev siv koj cov FoodShare nyiaj muas noj los tau. Tus tso cai lav yuav tau ib daim npav QUEST ua nws tus kheej npe. Koj yuav tsis tau daim QUEST npav. lossis Koj xav tshem cov uas koj tso cai rho koj cov FoodShare nyiaj muas noj thaum twg los tau. Yog koj xav tshem lawv npe, nrog tus lis dejnum tham lossis hu xovtooj rau QUEST Customer Service Help Line uas yog 1-877-415-5164. Lub Npe Siv Thov Kev Pabcuam Tus Zauv Thov Kev Pabcuam Tus Lis Dejnum Lub Npe

Thaum kuv kos lub (cov) thawv hauv qab no, kuv lav tias: Kuv xav taw ua kuv tus Tso Cai Siv rho tau kuv cov FoodShare nyiaj muas noj los yuav zaub mov rau kuv. Kuv to taub tias wb ob leeg nyias yuav tau nyias daim npav ua nyias npe. Kuv tus tso cai siv daim npav QUEST card yuav tsum muab xa mus rau: Txoj Kev (Street) Kuv xav tshem Lub Zos (City) tawm ua ib tug Tso Cai Siv. Xeev (State) . Zip Code

Kuv xav taw ua kuv tus Tso Cai Lav rho tau kuv cov FoodShare nyiaj muas noj los yuav zaub mov rau kuv. Kuv totaub tias tus Tso Cai Lav xwb thiaj yuav tau ib daim npav. Kuv tus tso cai lav daim npav QUEST card yuav tsum muab xa mus rau: Txoj Kev (Street) Kuv xav tshem Kuv to taub tias: Txhua zaus uas cov FoodShare nyiaj muas noj raug rho tawm los ntawm kuv tus kheej, los ntawm tus Tso Cai Siv, los ntawm tus Tso Cai Lav, lossis los ntawm lwm tus neeg uas kuv txaus siab muab kuv daim npav QUEST thiab tus PIN rau nws xam tias tau kev tso cai thiab cov nyiaj yuav tsis rov qab ntxiv rau kuv. Lwm tus neeg yuav tsum ua povthawj rau koj lub npesuam. Yog tias koj suam npe ua tus X xwb, yuav tsum muaj li ob leeg los ua povthawj. Lub Zos (City) tawm ua ib tug Tso Cai Lav. Xeev (State) . Zip Code

NPESUAM ­ Tus Tuav Npav lossis Tus Tso Cai Lav NPESUAM ­ Povthawj 1 (Yuav tsum muaj povthawj) NPESUAM ­ Povthawj 2 (Yog tias lub npe suam uas tus X xwb)

Hnubtim Suam Npe Hnubtim Suam Npe Hnubtim Suam Npe

LUS TSHAB: Koj muaj cai tsa lwm tus los pab koj teev/tshuaj ntaub ntawm thov kev pabcuam. Tus uas koj tsa yuav los ua tus sawv cev ntawm koj. Yog tias koj xav tso cai ib leeg twg los ua tus sawv cev ntawm koj, muab daim ntawv "Medicaid/BadgerCare Plus/ FoodShare Authorization of Participant's Representative" (HCF 10126H) los teev. Yog koj xav tau daim ntawv no, nrog tus lis dejnum tham lossis mus xyuas hauv dhfs.wisconsin.gov/forms/DHCF/HCF10126H.pdf. For Case Worker Use Only New Alternate Payee Remove Authorized Buyer Date Signed

New Authorized Buyer SIGNATURE ­ IM Worker

Remove Alternate Payee

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Case File ­ Original

Member ­ Copy

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