STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10175 (07/08)
ID
STATEMENT OF IDENTITY FOR PERSONS IN INSTITUTIONAL CARE FACILITIES
This statement may be used as proof of identity for the Medicaid, BadgerCare Plus and family planning services programs only when no other proof exists. This statement may be used to provide proof of identity for individuals who reside in the following: · · · · Skilled nursing facility, Intermediate care facility, Institutions for mental disease, or Hospitals.
The individual signing this statement must be the facility director or administrator. Return the completed form to the local county/tribal office. Identity Statement By completing this section, I attest to the identity of the individual named below.
Print Name Applicant / Member
Case or Social Security Number
By signing this statement I certify under penalty of perjury and false swearing that the information I have given is correct and complete to the best of my knowledge. I understand that the local agency may contact other persons or organizations to confirm the accuracy of my statement.
SIGNATURE - Facility Director or Administrator
Date Signed
Print Name
Title
Note: This form cannot be used to provide proof of citizenship. To provide proof of citizenship, one of the items listed below can be used. If you are unable to obtain any of these items, contact the local agency. · · · · U.S. Birth certificate Hospital record of U.S. birth U.S. Citizenship ID card Adoption papers showing U.S. birth · · · · U.S. Military Record of Service Life or health insurance record showing U.S. birth U.S. State Department Report of Birth Abroad Nursing home admission papers showing U.S. birth
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