WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Access and Accountability HCF 10137R (02/08)
CHG
MEDICAID
MEDICAID CHANGE REPORT , , . access.wi.gov . , , Medicaid. / , 1-800-362-3002 dhfs.wisconsin.gov/medicaid1/contacts/index.htm. - , , , , , , . , , . - , , Medicaid ( ), . , . ( Medicaid)
, , Medicaid.
1
, . (, , , )
2
- , , ( , ). (, , /) Social Security Number (SSN)*
SSN . , , Wisconsin Medicaid, SSN , Wisconsin Statutes 49.82(2). Administrative Rule HSF 102.01 (6)
MEDICAID MEDICAID CHANGE REPORT HCF 10137R (01/08)
CHG
3
, , . (, , /)
$
4 /
, / ( ) . , , , .. $ ?
5
, , , , , . (, , /)
(, ..)
$
* $
$
* , , .
6
, , ( , ), , Social Security, Veterans benefits, Unemployment Insurance, Worker's Compensation , . (, , /) : $
. 2
MEDICAID MEDICAID CHANGE REPORT HCF 10137R (01/08)
CHG
7
, Medicaid. , . , , , .
, , , ? , .
8
, . , , , - ( Medicaid). , . , , .
, , .
. 3 ( )
RESET FORM