Free Interagency Notification of Termination of Medicaid Waiver Eligbility for a Community Waiver Participant, HCF 10142 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10142 (07/08)

STATE OF WISCONSIN

INTERAGENCY NOTIFICATION OF TERMINATION OF MEDICAID WAIVER ELIGIBILITY FOR A COMMUNITY WAIVER PARTICIPANT This form is to be filled out by the Income Maintenance worker and sent to the Care Manager/Support and Services Coordinator when the Medicaid Waiver participant loses Medicaid Waiver eligibility.

Name - Community Waiver Care Manager / Support and Services Coordinator

Name ­ Income Maintenance Worker

Name - Waiver Participant

Case Number Medicaid Waiver Termination Date Reason for Termination

Social Security Number

Additional Comments

SIGNATURE - IM SIGNATURE ­ CM / SSC

Date Sent Date Received

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