Free Medicaid, BadgerCare and Family Planning Waiver Registration Application, HCF 10129H - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Department of Health Care Financing HCF 10129H (01/03)

STATE OF WISCONSIN WI Stats. s. 49.47

MEDICAID, BADGERCARE AND FAMILY PLANNING WAIVER REGISTRATION APPLICATION
Teev daim ntawv thov kev pab no yuav muab tso rau Medicaid Mes Dis Khes, BadgerCare thiab Family Planning Waiver Npaj Kev Pab Rau Tsev Neeg Yam Tsis Them Nqi. Koj tsuas tau teev yav hauv qab no thiaj li yuav teem tau hnub uas koj thov kev pab. Tiam sis, yuav tsum ua kom tag nrho Medicaid Mes Dis Khes, BadgerCare, thiab Family Planning Kev Pab Rau Tsev Neeg Yam Tsis Them Nqi ua ntej koj tau txais kev pab. Mam li qhia rau koj li ntawm 30 hnub seb koj puas tsim nyog los tsis tsim nyog. Nws tseem ceeb heev uas koj tso hnub rau koj daim ntawv thov kev pab kom sai li sai tau vim tias yog tias koj tsim nyog, tej zaum koj yuav tau txais kev pab pib hnub uas koj tso hnub rau. Kev pab Medicaid Mes Dis Khes rau cov neeg tsim nyog tej zaum yuav mus tau rov qab li peb lub hlis pib hnub uas tso hnub rau daim ntawv thov kev pab. BadgerCare thiab Family Planning Waiver Kev Pab Rau Tsev Neeg Yam Tsis Them Nqi yuav mus tsis tau rov qab. Koj thov tau kev pab rau Medicaid/BadgerCare Mes Dis Khes/BadgerCare hauv kev xa ntawv, xov tooj los sis tuaj tim ntsej tim muag. Yog tias koj xav thov kev pab hauv kev xa ntawv, koj nqa tau ib daim ntawv thov kev pab rau Wisconsin Medicaid/BadgerCare Family Viv Xis Kas Xees Mes Di Khes/BadgerCare tom koj lub nroog nruab ze/tej pawg neeg los sis laj fai pab neeg. Xav teem sij hawm tuaj thov kev pab tim ntsej tim muag los sis hauv xov tooj hu rau koj lub nroog nruab ze/tej pawg neeg los sis laj fai pab neeg. Yog tias koj tim tsum ib tug neeg tuaj txhais lus los sis lwm yam kev pab teev daim ntawv no, thov nug. Koj tso tau lwm tus neeg laus los sawv cev koj thiab los ua kom meej qhov thov kev pab no. Koj thaj tsob rau tag nrho cov moj kab sim uas tau muab, txawm tias tus neeg sawv cev rau koj yog tus los ua kom meej qhov thov kev pab rau koj. Kawm moj kab sim txog Mes Dis Khes, nrog rau koj cov cai thiab thiv meem hauv phau ntawv "Wisconsin Medicaid Program ­ Eligibility and Benefits Viv Xis Kas Xees Kev Pab Mes Dis Khes--Kev Tsim Nyog thiab Kev Pab". Yog tias koj tsis tau ib phau, thov nug hauv koj lub nroog nruab ze/tej pawg neeg. Yog tias koj muaj lus nug txog koj cov cai thiab thiv meem, thov nug. ------------------------------------------------------------------------------------------------Kev Qhia rau Cov Neeg Thov Kev Pab: Siv cwj meem xiav los sis dub xwb. Tsis txhob sau hauv seem tsos.
Nyob hauv Viv Xis Kas Xees Tshooj Cai seem 49.45(4), cov moj kab sim uas yuav qhia tau tias koj yog leej twg tsuas ncaj qha hauv laj fai hauv kev pab Medicaid Mes Dis Khes xwb. *Qhov muab los sis thov ib tug Zauv Pua Cev (SSN) tsuas yog yus yeem yus xwb; tiam sis cov neeg uas thov kev pab los ntawm Viv Xis Kas Xees Kev Pab Medicaid Mes Dis Khes tiam sis tsis xav muab lawv tus SSN los sis tsis thov ib tug yuav tsis tsim nyog txais kev pab, raws Viv Xis Kas Xees Tshooj Cai seem 49.82(2). Koj tus SSN cia lub kaib lawj ceem soj ntsuam koj cov moj kab sim nrog rau lwm cov laj fai hauv tsoom fwv, xws li Internal Revenue Service (IRS) Chaw Tuav Se, federal Social Security Administration (SSA) Laj Fai Saib Xyuas Cov Nyiaj rau Cov Neeg Ib Ce Tsis Meej Xeeb Pem thiab Wisconsin Department of Workforce Development Caj Meem Fai Saib Xyuas Kev ua hauj Lwm. Ntxiv mus, kev pab Medicaid Mes Dis Khes yuav muab koj lub npe thiab SSN nrog rau cov moj kab sim uas tuam txhab tuav pov hwm kev mob nkeeg los xyuas seb koj puab muaj lwm qhov kev pab tuav pov hwm.

RFA / Case Number

Zauv Pua Cev

Hnub Yug (mm/dd/yyyy)

Zeej Xeeb (kos ib qho) Txiv neej Poj niam Xov Tooj

Tus Thov Kev Pab Lub Npe (Xeem, Npe, tus ntawv cim npe nrab) Chaw Nyob (Txoj kev, Nroog, Xeev, Zauv Cheeb Tsam)
XYEEM MEEM TES ­ Tus thov kev pab

Hnub Xyeem Npe

Khaws sab saum toj hauv daim ntawv no rau koj. Xa sab hauv qab ntawm daim ntawv no mus rau: (Nroog/pawg neeg los sis caj meem fai pab neeg yuav tsum ntaus thwj los sis sau qhov chaw nyob seb yuav xa rau qhov twg.)

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