Free Wisconsin Adult Cystic Fibrosis Program Application, F-1185 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1185 (02/09)

STATE OF WISCONSIN ss. 49.683 WIS STATS

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM APPLICATION
READ INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM SECTION 1. APPLICANT INFORMATION
1. Name ­ Applicant (Last, First, MI) 2. Social Security Number (SSN) (optional)

3. Street Address ­ Applicant

4. Home Telephone

5. City, State, ZIP Code

6. County of Residence

7. Sex Male 9. Female

8. Date of Birth

Do you have any dependent family members who are also members of the Chronic Disease Program? Yes No If Yes, indicate the names and Social Security Numbers (SSN) of all dependent family members who are also members of the Chronic Disease program. Name _______________________________________________ Name _______________________________________________ SSN SSN

10. Race/Ethnicity (Optional) American Indian or Alaska Native Black (Not of Hispanic Origin)

Asian or Pacific Islander White (Not of Hispanic Origin)

Hispanic (Mexican, Puerto Rican, Cuban or other Hispanic Culture)

SECTION 2. RESIDENCY INFORMATION
11. Have you lived in Wisconsin for the last 2 years? Yes No If you answered No, indicate the date you moved to Wisconsin. __________________________________________ 12a. Applicants age 19 and over should provide copies of the 12b. Applicants under the age of 19 should provide copies of the following documents. following documents. · Last year's Wisconsin Income Tax return with all · Parent or guardian's Wisconsin Income Tax return with all attachments. attachments for the last year. · The most recent rental agreement or property tax bill. · Parent or guardian's most recent rental agreement or property tax bill. · Wisconsin drivers license with current address OR state identification with current address. · Wisconsin drivers license with current address OR state identification with current address OR school identification. · Alien registration card issued by the INS if you are not a U.S. citizen. · Alien registration card issued by the INS if you are not a U.S. citizen. 13. If you do not have these documents, explain why.

SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
14. Do you currently have or have you had Medicare coverage? If yes, indicate your Medicare eligibility dates below. Part A Begin Date Part A End Date _____________ _____________ Part B Begin Date ________________ Part B End Date ________________ Part D Begin Date ________________ Part D End Date Yes No

______________

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM APPLICATION F-1185 (02/09)

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15. Wisconsin law requires applicants must first complete applications for other health care programs, if they may be reasonably eligible given their financial and non-financial circumstances, before applying to WCDP. Are you currently eligible for Wisconsin Medicaid, BadgerCare Plus (Medical Assistance, MA, Title 19, T-19), or SeniorCare? Yes No If yes, indicate your Medicaid, BadgerCare Plus, or SeniorCare identification number here__________________________________. 16. If no, have you applied for any of these programs in the past year? Yes No If yes, and you were denied eligibility for these programs, explain why. _________________________________________________________________________________________________________.

SECTION 4. SOCIAL WORKER SIGN OFF
This section is to be completed by the social worker if the applicant is not enrolled in Wisconsin Medicaid, BadgerCare Plus, or SeniorCare. 17. Based on my knowledge of _________________________________________________________, I attest that he/she is not eligible for the programs listed above. Explain in the space provided why the applicant would be denied eligibility, where applicable. Medicaid or BadgerCare Plus__________________________________________________________________________________

SeniorCare________________________________________________________________________________________________

SIGNATURE ­ Social Worker

Facility Name

Date Signed

SECTION 5. INSURANCE INFORMATION
18. In the last two years have you had or do you currently have private, group, HIRSP, or other health insurance coverage for medical expenses? (Do not include Medicare, Wisconsin Medicaid, BadgerCare Plus, or SeniorCare information here.) Yes No If yes, complete the following information. If you have more than one insurance company, list the second company under Insurance #2. Attach additional information if needed for current and past insurance for the last two years. Insurance #1 Insurance #2 a. Name ­ Insurance Company b. Telephone Number a. Name ­ Insurance Company b. Telephone Number c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date
d. Relationship of Policy Holder

c. Name ­ Policy Holder e. Policy Number g. Coverage Begin Date

d. Relationship of Policy Holder

f. Group Policy Number h. Coverage Termination Date

f. Group Policy Number h. Coverage Termination Date

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes No j. Outpatient Hospital Service. k. Physician Services. l. Radiology Services. m. Laboratory Services. n. Prescription Drugs. Yes Yes Yes Yes Yes No No No No No

Indicate whether this insurance covers these services by answering each question. Answer each question. i. Inpatient Hospital Service. Yes No j. Outpatient Hospital Service. k. Physician Services. l. Radiology Services. m. Laboratory Services. n. Prescription Drugs. Yes Yes Yes Yes Yes No No No No No

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM APPLICATION F-1185 (02/09)

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SECTION 6. FINANCIAL INFORMATION
19. Indicate the number of dependent family members; include yourself if you are a dependent family member. _____________________

20. Indicate your current total income by completing items a - m either by

monthly OR annual totals.
a. Gross wages, salaries, tips, etc. b. Net income from non-farm self-employment. c. Net income from farm self employment. d. Social Security and/or Supplemental Security benefits. e. Dividends and interest income. f. Total of estate or trust income, net rental income and royalties. g. Cash public benefits (e.g. W-2 payments). h. Pensions, annuities and/or veteran's pension. i. Unemployment compensation and/or worker's compensation. j. Maintenance, alimony and/or child support. k. Non taxable interest (federal, state or municipal bonds). l. Nontaxable deferred compensation. m. Total Monthly OR Yearly Income. 21. Do you expect this income to change significantly from month to month or in the next year? 22. If yes, will your income be less or more than the total above? Explain why. Less More

Average Monthly Totals OR ________ 2 0__ __
Month Year

Annual Totals 2 0 __ __
Year

$ $ $ $ $ $ $ $ $ $ $ $ $ Yes

$ $ $ $ $ $ $ $ $ $ $ $ $ No

23. On last year's Wisconsin Income Tax return, what was your total gross family income before taxes? $_______________________

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM APPLICATION F-1185 (02/09)

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SECTION 7. AGREEMENT AND SIGNATURES FOR ADULT CYSTIC FIBROSIS APPLICANTS Eligibility for state reimbursement exists only insofar as certified by the Department of Health Services (herein called the Department) or its fiscal agent upon: a) determination of the member's Wisconsin residency; b) receipt of completed application, including verification by the medical director of a certified Wisconsin cystic fibrosis treatment center of having cystic fibrosis; c) must be 18 years of age or older. Pursuant to the authority of Wisconsin Statute 49.683 and 49.687 and the rules promulgated thereunder, the Department or its fiscal agent will, subject to the conditions named, reimburse an approved provider, on behalf of the member, for part of the cost of medical treatment specifically relating to cystic fibrosis. Reimbursement will be made only for that portion of the allowable cost of medical services and medication remaining after all payment from other state programs, federal programs, and private health insurance coverage have been received and the member's liability and deductibles have been determined. The member's liability and deductibles will be based on income and family size. Wisconsin Administrative Code 154 specifies the methodology for provider reimbursement. Charges in excess of what the Adult Cystic Fibrosis Program allows are the individual responsibility of the member. If insufficient aid is available from other sources, the state shall pay the difference between the allowable cost and the sum of payment received and member liability and deductibles. State payment shall be appropriately reduced if federal, state, private or other health insurance becomes available during the benefit period. The member must inform the Department or its fiscal agent of all health insurance coverage and eligibility date. The Department, the State of Wisconsin, and its officers or agents are released and discharged of and from all manner of action and actions, cause and causes of actions, suits, sums of money, judgement, claims, and demands whatsoever in law or in equity which the claimant, or his/her heirs, executors or assignees might have, or may hereinafter have, by reason of any injury or worsening of condition or death of the member due to cystic fibrosis, treatment or lack of treatment. In order to establish my eligibility for state benefits, I authorize the medical facility (24)__________________________ to disclose information relating to my health condition or payment made for my health care to the Adult Cystic Fibrosis Program. I certify, to the best of my knowledge, all information provided on this form is true, correct, and complete. I understand that I will be denied reimbursement if I withhold information, provide inaccurate information, or refuse to provide information. I authorize release of any medical and financial information including certification for General Assistance, Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare to the Wisconsin Chronic Disease Program necessary for processing claims and verifying services under the program. I agree to notify the Department or its fiscal agent in writing within 30 days of any change in name, address, income by more than 10%, insurance coverage, or family size. I agree to accept responsibility for the program's copayments and deductibles. I have read and consent to the above. I understand that benefits issued through the Wisconsin Chronic Disease Program are eligible for estate recovery as defined in HFS 154.07(5). I understand that only Wisconsin residents are eligible for the Chronic Disease Program. By signing this form I am attesting that I am a Wisconsin resident as set forth in HFS 154.02(16).
25. SIGNATURE ­ Applicant (or applicant's representative if applicant is a minor) Date Signed

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM APPLICATION F-1185 (02/09)

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SECTION 8. ADULT CYSTIC FIBROSIS PATIENT MEDICAL INFORMATION Section 8 is to be completed by the medical director at an approved cystic fibrosis treatment center.
26. Name ­ Patient (Last, First, MI) 27. Patient's primary diagnosis (Use ICD-9-CM code)

28. Date Patient was diagnosed with cystic fibrosis ________________________ . 29. Name ­ Treating Facility 30. Wisconsin Medicaid or BadgerCare Plus Provider identification number of facility

31. Address ­ Treating Facility

I certify that the above patient has been diagnosed to have cystic fibrosis.
32. SIGNATURE ­ Medical Director Date Signed

Send completed application to:

Wisconsin Chronic Disease Program Attn: Eligibility Unit P.O. Box 6410 Madison, WI 53716-0410

OFFICE USE ONLY. DO NOT WRITE IN THIS SPACE.