Free None - Wisconsin


File Size: 117.3 kB
Pages: 1
Date: October 15, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHCAA-BOC
Word Count: 261 Words, 1,688 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/F1/F10122.pdf

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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10122 (07/08) WI Stats. s. 49.472

ME

MEDICAID PURCHASE PLAN (MAPP) MEMBER/PREMIUM INFORMATION
This form is to be completed by Income Maintenance workers for updates on member information, including member demographic information and premium information.

SECTION I MEMBER INFORMATION
Member Information (check one) Add Change Member Name (Last, First, MI) Date Completed Worker ID

Mailing Address (Street)

City

State

Zip Code

Social Security Number*

Medicaid ID Number

SECTION II PREMIUM INFORMATION
Premium Information (check one) Add Change Premium Payer Name (Last, First, MI) Date Completed Premium Payer PIN

Benefit Month

Premium Amount

Amount Paid

*Providing or applying for a Social Security Number (SSN) is voluntary; however any person who wants Wisconsin Medicaid but does not want to provide their SSN or apply for one will not be enrolled in Medicaid, pursuant to Wisconsin Statutes s. 49.82(2). SSN information will be used for administration of the Medicaid program. Your SSN permits a computer check of your information with government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Wisconsin Department of Workforce Development. In addition, your name and SSN will be matched with other information provided by health insurance carriers to determine if you have other health insurance. Send this form, along with any premium payments due, to: Medicaid Purchase Plan P.O. Box 6738 Madison, WI 53716-0738 If you have questions, call the Medicaid Purchase Plan Premium Unit at 1-888-907-4455.

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