Free Medicaid, BadgerCare Plus and Family Planning Services Registration Application, HCF 10129 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10129 (07/08)

APP

MEDICAID, BADGERCARE PLUS AND FAMILY PLANNING SERVICES REGISTRATION APPLICATION
Completing this form will set your application date for Medicaid, BadgerCare Plus and family planning services. You only have to complete the bottom portion of this application in order to set your application date. However, the entire Medicaid, Badgercare Plus and family planning services application process must be completed before you can get benefits. You will be notified within 30 days whether or not you are enrolled. It is important to set your application date as soon as you can because if you are enrolled, you will only get benefits from your application date. Medicaid benefits and certain BadgerCare Plus plans may be backdated up to three months beginning prior to the application date, if enrolled. Some Badgercare Plus and family planning services benefits cannot be backdated. You can apply online at access.wi.gov, by mail, telephone or in person. If you choose to apply by mail, you may get a Wisconsin Medicaid or Badgercare Plus application at your local county or tribal agency. To schedule an appointment to apply in person or by telephone contact your local agency. If you need an interpreter or other help in completing this form, ask for help. You may have another adult act as an authorized representative and complete the application process. You are responsible for all information provided, even if an authorized representative completes the application process for you. Learn about general information, as well as your rights and responsibilities in the "Wisconsin Medicaid ­ Enrollment and Benefits" or "BadgerCare Plus Enrollment and Benefits" brochures. If you do not have one, ask for one at your local agency. If you have questions about your rights and responsibilities, please ask about them. --------------------------------------------------------------------------------------Instructions to Applicant: Use only blue or black ink. Do not complete shaded area.
Under Wisconsin Statute section 49.45(4), personally identifiable information is only used directly for the administration of the Medicaid and BadgerCare Plus programs. *Providing or applying for a Social Security Number (SSN) is voluntary; however any person who wants Wisconsin Medicaid and/or BadgerCare Plus but does not want to provide their SSN or apply for one will not be eligible for benefits, pursuant to Wisconsin Statutes section 49.82(2). Your SSN permits a computer check of your information with other government agencies, such as the federal Internal Revenue Service (IRS), federal Social Security Administration (SSA) and the Wisconsin Department of Workforce Development. In addition, the BadgerCare Plus and Medicaid programs will match your name and SSN with information provided by health insurance carriers to determine if you have other health insurance.

RFA / Case Number

Social Security Number*

Birthdate (mm/dd/yy)

Gender (check one) Male Female

Applicant Name (Last, First, MI)

Telephone Number

Address (Street, City, State, Zip Code)

SIGNATURE ­ Applicant

Date Signed

Keep the top portion of page for your records. Return the bottom portion of this form to: (County or tribal agency must stamp or write in address of where to return form.)

WI Stats. s. 49.47

RESET FORM