Free Medicaid Purchase Plan (MAPP) Independence Account Registration, F-10121 - Wisconsin


File Size: 29.1 kB
Pages: 1
Date: September 18, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BEM
Word Count: 150 Words, 1,050 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F10121.pdf

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Preview Medicaid Purchase Plan (MAPP) Independence Account Registration, F-10121
STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10121 (09/08)

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MEDICAID PURCHASE PLAN (MAPP) INDEPENDENCE ACCOUNT REGISTRATION

Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants Wisconsin Medicaid but does not provide an SSN or apply for one will not be eligible for benefits. SSNs and personally identifiable information will be used only for the direct administration of the Medicaid Program.

Member Name

Social Security Number

Filing Date

CARES Case Number

Worker Number

PIN Number

AALA Liquid Asset Type

AALA Sequence Number

Date Opened

MAPP Enrollment Determination Date

Independence Account Type

Independence Account Number

Balance-to-Date $

Financial Institution Name Financial Institution Address - Street City

Telephone Number State, Zip Code

Worker Name

Date

Approved Not Approved

Reason for Non-Approval (per HFS 103.06(15))

DISTRIBUTION:

Case File

Member (or his/her Authorized Representative)

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