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