STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10121 (09/08)
BNK
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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