Free Medicaid Change Report, HCF 10137 - Wisconsin


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State: Wisconsin
Category: Health Care
Author: DHCAA-BOC
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URL

http://dhs.wisconsin.gov/forms/F1/F10137.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 10137 (01/08)

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MEDICAID CHANGE REPORT

If you are receiving Medicaid, you must report any changes in the make up of your household (if anyone moves in or out of your household, if anyone gets married, becomes pregnant, or gives birth to a child), address, income, employment status or changes in assets within 10 days. You can report changes online at access.wi.gov, by filling out this report and mailing it or taking it to the office shown in the box below, or contact your worker by telephone or in person. If this report does not provide enough room to document a change, attach a sheet of paper with the additional information written on it to this report. (County agency address)

Your Name

Case Number

Worker Name

If you intentionally fail to report any changes or provide false information, you may be fined, have to pay back any Medicaid benefits you wrongfully received, be prosecuted, or all three. You may be required to provide proof of any changes you report.

SECTION I - CHANGE IN ADDRESS
If you move, you must report your new address. Date of change New telephone number

New address (street, city, state, zip code)

SECTION II - CHANGE IN HOUSEHOLD COMPOSITION
You must report if anyone moves in or out of your household, if anyone gets married, becomes pregnant, or gives birth to a baby (include information about the person who gave birth and the newborn.) Name(s) (Last, First, MI) Date of change

Social Security Number (SSN)*

Date of birth

Relationship to Case Head

Describe the change

*Providing or applying for an SSN is voluntary; however any person who wants Wisconsin Medicaid but does not provide their SSN or apply for one will not be eligible for benefits [§49.82(2) Wis. Stats.].

SECTION III - CHANGE IN INCOME
You must report a change in your gross income amount, a new source of income, changes in your employment status (part-time to full-time or full-time to part-time, loss of employment), changes in salary or rate of pay, changes in the amount of Social Security, Veterans benefits, Unemployment Insurance, Worker's Compensation, or any other change in the amount of money your household receives. Name (Last, First, MI) Date income changed

Source of income

Monthly amount

How often Paid

MEDICAID CHANGE REPORT HCF 10137 (02/08)

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Date of change

SECTION IV - CHANGE IN ASSETS
Examples of assets are cash, bank accounts, bonds, stocks, vehicles, etc. Name of owner (Last, First, MI)

Type of asset

Describe the change

New value or amount $

Name of owner (Last, First, MI)

Date of change

Type of asset

Describe the change

New value or amount $

SECTION V ­ CHANGE IN VEHICLES
Complete the following, if you obtain, sell or give away a car, truck, motorcycle, boat, snowmobile, camper, or another type of vehicle. Name of owner (last, first, MI) Date of change

Type of vehicle

Make

Model

Year

Amount received $

Describe change (bought, sold, etc.)

SECTION VI - OTHER CHANGES
Report any other changes that you believe may affect your Medicaid enrollment. Examples of other changes include someone getting or dropping health insurance or someone becoming disabled or recovering from a disability. Include the date of any other change. Describe change

Do you expect that the changes reported on this form will remain the same next month? If No, explain.

Yes

No

SECTION VII ­ SIGNATURE
I understand that there are penalties for hiding information or giving false information. I also understand that I may have to pay back any benefits I receive because I do not fully report changes in my circumstances. I agree to provide proof of any changes, if asked to do so. My answers on this form are correct and complete to the best of my knowledge. SIGNATURE ­ Member Date signed Telephone number

RETAIN COMPLETED FORM IN CASE FILE (FOR AGENCY USE ONLY)

RESET FORM
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