Free Statement of Identity for Children Under 16 Years of Age, HCF 10154H - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10154H (07/08)

ID

NQAI LUS LEES PAUB RAU COV MENYUAM HNUB NYOOG QI DUA 16 XYOO STATEMENT OF IDENTITY FOR CHILDREN UNDER 16 YEARS OF AGE
Cov nqai lus lees paub no tsuas yog yuav siv coj los ua kom haum li Medicaid/BadgerCare/Family Planning Waiver Program txoj cai tshiab txog kev lees paub cov menyuam hnub nyoog qi dua 16 xyoo xwb. Cov nqai lus lees paub no yuav siv tsis tau coj los ua kom haum li Medicaid/BadgerCare/Family Planning Waiver Program txoj cai txog ntaub ntawv pov thawj txia ua pejxeem. Lus Qhia: Rau hauv cov kab ntawv npaj tseg nram qab no, teev tag nrho cov menyuam hnub nyoog qi dua 16 xyoo nyob hauv koj tsev neeg uas koj yog ua niam ua txiv, tus saib xyuas, lossis tus tu. Rau txhua tus menyuam uas koj teev, qhia tus menyuam lub hnub yug thiab chaw yug (zos, xeev, thiab tuamnroog). Teev daim ntawv no kom tiav, kos npe rau thiab muab xa rov qab mus rau lub chaw pab cuam ntawv kho mob Medicaid ntawm koj. Menyuam Lub Npe (Npe, MI, Xeem) Hnub Yug Chaw Yug (Zos, Xeev, Tuamnroog) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Cov xwm uas qhia txog tus kheej tsuas yog siv los tswj kev pabcuam Medicaid xwb. Los ntawm kev suam npe rau cov nqai lus no, kuv lees, yam uas paub tias yuav muaj txim yog tias dag thiab muab lus tsis tseeb, tias cov xwm uas kuv muab yeej yog thiab meej raws li kuv paub. Kuv nkag siab tias lub chaw ua haujlwm hauv zos tej zaum yuav nug lwm tus neeg lossis tej koomhaum pab ua pov thawj tias kuv cov nqai lus yeej yog tiag. NPE SUAM (Niam los Txiv, Tus Saib Xyuas, lossis Tus Tu) Sau Npe (Niam los Txiv, Tus Saib Xyuas, lossis Tus Tu) Hnub Suam Npe ____________ _____ _____

Zauv Cim Ntaub Ntawv

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