Free Medicaid Manual Notice For Cost of Care Contribution, HCF 10108 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10108A (07/08)

STATE OF WISCONSIN WI Stats. s. 49.46

MEDICAID MANUAL NOTICE FOR COST OF CARE CONTRIBUTION INSTRUCTIONS
The Medicaid Manual Notice for Cost of Care Contribution form is to be completed by the Economic Support (ES) worker. Original to institution or nursing home, copy to client and copy filed in case record. SECTION I ­ CLIENT INFORMATION New Client Information Check "Yes" if this is a new client for which you are providing information. Check "No" if the information is not for a new client. Changed Client Information Check "Yes" if this is a change to information regarding this client. Check "No" if this is not a change to this client's information. Termination Date Enter termination date. Medicaid Number Enter the client's Medicaid number. Medicaid Categorically Needy Check "Yes" if this client is Medicaid categorically needy. Check "No" if this client is not Medicaid categorically needy. Medicaid Medically Needy Check "Yes" if this client is Medicaid medically needy. Check "No" if this client is not Medicaid medically needy. Medicare Number Enter the client's Medicare number. Medicare Part A Check "Yes" if the client has Medicare Part A. Check "No" if the client does not have Medicare Part A. Medicare Part B Check "Yes" if the client has Medicare Part B. Check "No" if the client does not have Medicare Part B. Client Name Enter the client's name, last, first and middle initial. Name of Institution / Nursing Home Enter the name of the institution or the nursing home where the client is.

NOTICE TO INSTITUTIONS, NURSING HOME, CLIENT INSTRUCTIONS F-10108A (07/08)

Admission Date Enter the date of admission of the client to the institution or nursing home. For example, if the date of admission is June 10, 2002, enter 06/10/02. Insurance Company Name If the client has other health insurance enter the name of the insurance company. Policy Number Enter the client's policy number for their insurance. Cost of Care Effective Date Enter the date of the cost of care became effective. Cost of Care Contribution Enter the amount of the client's cost of care contribution (see Medicaid handbook, Institutions section to determine the client's cost of care). SECTION II ­ SIGNATURE Signature Economic support worker is to sign the completed form in this field. County Name Enter the name of the county where ES worker is employed. Date Signed Enter the date the form was signed.