Free None - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10126H (07/08)

REP

MEDICAID/BAGERCARE PLUS/FOODSHARE WISCONSIN DAIM NTAWV TSO CAI SAWV CEV MEDICAID/BADGERCARE PLUS/FOODSHARE WISCONSIN AUTHORIZATION OF REPRESENTATIVE
Tus uas teev daim ntawv thov kev pab Medicaid, BadgerCare Plus thiab/los yog FoodShare Wisconsin sawv cev rau ib tus thov kev pab yuav tsum teev daim ntawv no. Cov Social Security Numbers thiab txhua yam uas qhia txog tus neeg yuav muab los siv rau kev tswj hwm khiav ntaub ntawv rau Medicaid, BadherCare Plus thiab FoodShare Wisconsin nkaus xwb. Qhov uas kom muab tus Social Security Number tso rau ntawm daim ntawv no tsuas yog siv los qhia kom paub meej ib tus tswv cuab (member) uas nws twb nyob hauv peb qhov kev pab cuam lawm xwb. Puas yog koj teev daim ntawv thov kev pab rau Medicaid, BadgerCare Plus los yog FoodShare Wisconsin sawv cev rau lwm tus neeg thiab koj puas yog tus tsev hais plaub tsa los ua tus saib xyuas, tus pab ceev los sis tus muaj cai los tuav tej nyiaj Yog Tsis yog txiag rau tus neeg ntawd? Yog koj teb tias "Yog", ces nres rau ntawm no. Koj yuav tsum muab, rau lub county los yog tribal qhov chaw ua hauj lwm ntawm koj, daim ntawv pov thawj tso cai uas tsev hais paub muab rau koj ua tus muaj cai saib xyuas tus neeg no los sis muaj cai los tuav nws tej nyiaj txiag. Koj puas yog ib tug neeg tau kev tso cai los teev daim ntawv thov Medicaid, BadgerCare Plus los yog FoodShare Wisconsin Yog Tsis yog rau lwm tus neeg? Yog tias koj yog ib Tus Neeg Tau Kev Tso Cai Sawv Cev los teev daim ntawv thov kev pab Medicaid, BadgerCare Plus los yog FoodShare Wisconsin rau lwm tus, ces koj thiab tus thov kev pab yuav tsum teb cov lus hauv qab no thiab koj yuav tsum kos npe rau Nqe Lus hais txog Cov Cai thiab Cov Luag Hauj Lwm hauv Daim Ntawv Thov Kev Pab Medicaid, BadgerCare Plus thiab/los yog FoodShare Wisconsin. Tsis tas li, koj thiab tus neeg thov kev pab neb ob leeg yuav tsum kos npe rau daim ntawv no xwv koj thiaj li yuav ua tau ib tug tau kev tso cai sawv cev.

Npe ­ Tus Tau Kev Tso Cai Sawv Cev (Xeem, Npe, MI)

Xov Tooj (Nrog Rau Tus Area Code)

Chaw Nyob (Txoj Kev, Lub Zos, Lub Xeev, Tus Zip Code)

E-mail Qhov Chaw Nyob

Medicaid/BadgerCare Plus

Kuv (npe ntawm tus thov kev pab/tus tswv cuab) tso cai rau tus muaj npe saum toj no los sawv cev rau kuv hauv kuv daim ntawv thov kev pab rau Medicaid/BadgerCare Plus uas muab xa rau lub county los yog tribal qhov chaw ua hauj lwm pab neeg uas yog tus saib xyuas txog qhov kev pab thiab kev soj ntsuam kuv qhov ua npe zwm rau kev pab. Kuv tseem tso cai rau kuv tus sawv cev los muab tej ntaub ntawv uas yuav tau muaj los mus txiav txim rau kuv qhov kev tsim nyog tau txais Medicaid/BadgerCare Plus. Kuv yuav muab txhua yam hais txog kuv tus kheej rau kuv tus sawv cev uas muaj tseeb thiab yog raws li qhov kuv paub. Kuv tus sawv cev thiab kuv to taub tias cov kev nplua rau tej lus uas qhia tsis yog yuav raug nplua mus txog $10,000 thiab yuav raug kaw tsis tshaj ib xyoos nyob rau hauv county lub tsev kaw neeg.

MEDICAID/BAGERCARE PLUS/FOODSHARE WISCONSIN DAIM NTAWV TSO CAI SAWV CEV F-10126H (07/08)

FoodShare Wisconsin (npe ntawm tus thov kev pab/tus tswv cuab) tso cai rau tus muaj npe Kuv saum toj no los sawv cev rau kuv hauv kuv daim ntawv thov kev pab/kev rov ntsuam xyuas dua rau FoodShare Wisconsin. Kuv tseem tso cai rau kuv tus sawv cev los muab tej ntaub ntawv uas yuav tau muaj los mus txiav txim rau kuv qhov ua npe zwm rau FoodShare Wisconsin. Kuv yuav muab txhua yam hais txog kuv tus kheej rau kuv tus sawv cev uas muaj tseeb thiab yog raws li qhov kuv paub. Kuv tus sawv cev thiab kuv to taub tias cov kev nplua rau tej lus uas qhia tsis yog yuav raug tsis pub thov kev pab FoodShare Wisconsin mus li 12 lub hlis rau thawj zaug, 24 lub hlis rau zaum ob thiab tsis pub mus tas sim neej rau zaum peb. Nyob ntawm seb cov nyiaj uas muab siv tas lawm es tsis raws cai muaj npaum li cas, tus neeg ntawd tseem yuav raug nplua txog $250,000, raug kaw txog 20 xyoo, los yog ob qho tib si. Qhov chaw txiav txim plaub ntug tseem muaj cuab kav txwv tsis pub tus neeg nkag rau kev pab 18 lub hlis ntxiv thiab. Ib tus neeg yuav koom tsis tau rau hauv FoodShare mus txog 10 xyoo yog thaum tshawb tau tias nws qhia tsis ncaj los yog muab nws tus kheej dag ua ntau tus neeg nyob ntau qhov chaw kom tau txais ntau yam kev pab rau tib lub sij hawm.

(LUS CIM: Lwm tus neeg uas tsis yog koj tus sawv cev yuav tsum ua pov thawj thaum koj kos npe. Yuav tsum muaj ob tug neeg ua pov thawj kos lawv lub npe yog koj kos npe siv tus "X".) KOS NPE ­ Tus Neeg Thov Kev Pab Social Security Number Hnub Kos Npe

KOS NPE ­ Tus Ua Pov Thawj (Yuav tsum tau muaj)

Hnub Kos Npe

KOS NPE - Tus Ua Pov Thawj (Yuav tsum tau muaj yog koj kos npe siv tus "X")

Hnub Kos Npe

Ua ib tug tau kev tso cai los sawv cev kuv to taub tias kuv sawv cev tus neeg thov kev pab rau Medicaid, Badger Care Plus thiab/los yog FoodShare Wisconsin uas muaj npe nyob saum toj no thiab txhua yam muab hais rau hauv no muaj tseeb raws li qhov kuv paub. KOS NPE ­ Tus Tau Kev Tso Cai Sawv Cev Hnub Kos Npe

MUAB FAIB (DISTRIBUTION): Khaws Cia Hauv Phau Ntawv-Daim Tseem (Case File ­ Original)

Tus Tswv Cuab-Daim Qauv (Member ­ Copy)

RESET FORM

Phab 2