Free SeniorCare Application Instructions, HCF 10076AR - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 10076AR (Rev. 10/05)

STATE OF WISCONSIN Section 49.688, Wis. Stats.

SeniorCare , SeniorCare Prescription Drug Program. . SeniorCare Customer Service Hotline: 1-800-657-2038 ( ). , . Department of Health and Family Services : http://dhfs.wisconsin.gov/seniorcare/. · SeniorCare. SeniorCare 4-6 . . $30 ( ) ($60, SeniorCare). , . SeniorCare, 6-8 . , , . , SeniorCare Customer Service Hotline 1-800-657-2038. .

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SeniorCare Application Instructions - HCF 10076AR (Rev. 10/05)

Applicant and Spouse ( / ) I II - SeniorCare () (), () . () , , () (), () SeniorCare. : « » , () . SeniorCare . Wisconsin Resident ( ) , SeniorCare, , , : · · · . , .

U.S. Citizen ( ) ( () (), () ) SeniorCare , . Race ­ Ethnicity (/ ) ( ) , () (). , , . Marital Status ( ) / , , . / () () , « ()». () () , « ()». Social Security Number , , () () Social Security Numbers (SSN), , , () () SeniorCare. () () SeniorCare, / SSN. SSN , Wisconsin Statutes, 49.688 49.82(2). . SSN SeniorCare. SSN , Internal Revenue Service (IRS), Social Security Administration (SSA) Department of Workforce Development (DWD). , SSN , , , 2

SeniorCare Application Instructions - HCF 10076AR (Rev. 10/05)

. , SeniorCare . Mailing Address ( ) III Address () , , SeniorCare. , , . , , , « », , , , , , . Expected Annual Income ( ) IV- SeniorCare () (), () . 12 . . , , ( ). , , . Gross Social Security ( Social Security) ( 12 ) Social Security, () (), Medicare, . Gross Wages ( ) ( 12 ) , , , () () ( , ). . W-2 , , , 12 . . Interest, Dividends and Capital Gains (, ) ( 12 ) , , () (). , . , , Certificate of Deposit (CD) . Net Self-Employment Income ( ) ( 12 ) , () (). , () () . , , , , -, - 3

SeniorCare Application Instructions - HCF 10076AR (Rev. 10/05)

, IRS . , , . . "0". Retirement Income ( ) ( 12 ) , , (Individual Retirement Accounts, IRAs) , , , () (). Other Income ( ) ( 12 ) () (). , , , . , : 1. Supplemental Security Income (SSI). SSI , , , . 2. , , . 3. . 4. , , , , , . 5. , . 6. , : Homestead Tax Credit. . , Retired Senior Volunteer program, Service Corporation of Retired Executives Volunteers in Service to America. , . Federal Emergency Management Assistance (FEMA). Agent Orange Settlement Funds. The Foster Grandparents Program. . , , SeniorCare Customer Service Hotline : 1-800-657-2038. Grand Total ( ) ( 12 ) () , . , , SeniorCare Program. Signature of Applicant ( ) V . , , , , ­ , . . 4

SeniorCare Application Instructions - HCF 10076AR (Rev. 10/05)

Enrollment Fee ( ) VI , SeniorCare . Enrollment Fee ( ) $30, . $60, SeniorCare , () (). . , , «State of Wisconsin». SSN, SSN () , () SeniorCare. , SSN . . SeniorCare , 6-8 . - , , Medicare Premium Assistance Foodshare Wisconsin, 1-800-362-3002 Customer Service Hotline , . Medicare Premium Assistance , Medicare, Part A Part B. FoodShare Wisconsin , , . , . , , , / http://access.wisconsin.gov. , 6 25 , 15 . , ACCESS , , , . , , , , ( // ), / () (), 10 SeniorCare Customer Service Hotline: 1-800-657-2038. ( V ) , Wisconsin Department of Health and Family Services , SeniorCare. , , , . . ( ..), , . $10 000 , , . Fair Hearing, , . Fair Hearing, : 5

SeniorCare Application Instructions - HCF 10076AR (Rev. 10/05)

Wisconsin Department of Administration Division of Hearings and Appeals P.O. Box 7875 Madison, WI 53707-7875 Department of Health and Family Services -, . , , : (608) 266-3465 (888) 701-1251 (). . , : Civil Rights Compliance Officer Wisconsin Department of Health and Family Services Office of Affirmative Action and Civil Rights Compliance 1 W. Wilson Street, Room 561 P.O. Box 7850 Madison, WI 53707-7850 (608) 266-9372 (888) 701-1251(), (608)267-2147 () ? , , , , ? ? ($30 , $60 - () ()). , , SSN / SSN () ? « »? : SeniorCare P.O. Box 6710 Madison, WI 53716-0710

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$____________ x 12 = ___________ $____________ x 12 = ___________ + $____________ x 12 = ___________ $____________ x 12 = ___________ $__________ x _________ = ___________ + $__________ x _________ = ___________ $__________ x _________ = ___________ $__________ x _________ = ___________ + $__________ x _________ = ___________ $__________ x _________ = ___________ $ ____________

() $____________ x 12 = ___________ $____________ x 12 = ___________ + $____________ x 12 = ___________ $____________ x 12 = ___________ () $__________ x _________ = ___________ + $__________ x _________ = ___________ $__________ x _________ = ___________ () $__________ x _________ = ___________ + $__________ x _________ = ___________ $__________ x _________ = ___________ () $ _____________

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