Free Medicaid Well Women Determination, HCF 10075 - Wisconsin

STATE OF WISCONSIN DEPARTMENT OF HEALTH AND FAMILY SERVICES
Division of Health Care Financing HCF 10075 (Rev. 07/06)

MAS

WISCONSIN WELL WOMAN MEDICAID DETERMINATION
Instructions: YES NO, or The client must be currently enrolled in the Family Planning Waiver Program (FPWP) YES NO. If you answered "YES" to Well Woman Program, you must attach a copy of the DPH 4818 Well Woman Program (complete all sections, including the shaded section). Part A ­ Applicant Information - This section needs to be completed by the applicant. Completion of this form is required to enable the Medicaid program to authorize and pay for medical services provided to eligible recipients. Under 49.45 (4) WI Statutes, personally identifiable information about Medicaid applicants and recipients is confidential and is used for purposes directly related to the Medicaid program administration such as determining eligibility of the applicant. Failure to supply the information requested by this form may result in denial of Medicaid payment for the services. To be determined presumptively eligible for Well Woman Medicaid, the applicant must be a U.S. citizen. If she is not a U.S. citizen she may still be eligible, however, she will need to apply at the local county/tribal social human services agency. · Enter applicant's name. · Enter applicant's address (must be a Wisconsin address). · Enter applicant's Social Security Number (SSN). The provision of the SSN is required under Wisconsin Administrative code HFS 103.03 (4) for any person requesting medical services covered by the Medicaid program. The SSN will only be used to determine eligibility for Medicaid. If the SSN is not provided benefits may be denied. · Enter applicant's date of birth. Applicant must be 35 through 64 years of age or enrolled in the FPWP. · Applicant must sign and date the form. Part B ­ Diagnosing Provider - This section of the form is to be filled out by the Wisconsin Well Woman Program diagnosing provider or FPWP diagnosing provider. · Enter the name of the diagnosing provider who is attesting to the screening, diagnosis and treatment recommendation. · Enter the date the screen was done. · Enter the date of diagnosis. This date should be on or after the date of the screen. · Enter the diagnosis. It must be a diagnosis of a condition of breast or cervical cancer or pre-cancerous lesions requiring treatment. · The treatment recommended box must be checked "yes". · The diagnosing provider must sign with medical credential, indicating medical credential and date the form. · For Well Woman Program clients enter the begin date of presumptive eligibility. This is the date of diagnosis. Enter the end date of presumptive eligibility. This is the last day of the month following the month of diagnosis. Part C ­ Income Maintenance (IM) Worker can add comments as needed.

PART A - Applicant Information
Name ­ Last Street Address First City MI Social Security Number State Zip Birthdate (mm/dd/yy)

SIGNATURE ­ Applicant

U.S. citizen? Yes No

Date Signed (mm/dd/yy)

PART B ­ Diagnosing Provider- Must be NP, MD or DO
Name - Last First MI

Street Address - Diagnosing Provider

City

State

Zip

Date of Screen

Date of Diagnosis

Treatment recommended for breast cancer, pre-cancerous condition of the cervix, or cancer of the cervix? Yes No Breast cancer Pre-cancerous condition of the cervix Cancer of the cervix

Diagnosis: Must be one of the following diagnosis:

Presumptive Eligibility Dates (Women enrolled in Well Woman Program only.) Presumptive Eligibility Begin Date SIGNATURE / Credentials ­ Diagnosing Provider Presumptive Eligibility End Date
Date Signed (mm/dd/yy)

PART C ­ Agency Comments

Agency

IM Worker Only

Office Use

Wis. Stats. 49.473

White - IM

Yellow - Provider

Pink - Local Coordinating Agency for- WWWP Clients

Blue ­ Applicant

RESET FORM

WISCONSIN WELL WOMAN MEDICAID DETERMINATION HCF 10075 (Rev. 07/06)

REPORTING CHANGES You must report to the agency within 10 days: · If you move out of state, · If you turn 65 years of age, · If you obtain health insurance that pays for cancer treatment, · If you become eligible for Medicare (Parts A or B). YOU HAVE THE RIGHT TO A WRITTEN NOTICE from this agency before any action is taken to stop or reduce your Wisconsin Well Woman Medicaid benefits. For most actions, a notice will be mailed to you at least 10 days before the action is taken. YOU MAY REQUEST A FAIR HEARING if you disagree with any agency's action including your Wisconsin Well Woman Medicaid. You may request a fair hearing in writing or in person with the agency listed on the front of this notice. You may also request a fair hearing by writing to the Department of Administration, Division of Hearings and Appeals, PO Box 7875, Madison, WI 53707-7875 or by calling 1-608-266-7709. Your request must be received within 45 days of the action's effective date. In most cases, if your fair hearing request is received by the Division of Hearings and Appeals prior to the action's effective date, your benefits will not stop or be reduced. The benefits will continue at least until the decision on your appeal is made. During this time, if another unrelated change occurs, your benefits may change. If another change occurs, you will receive a new notice. If you are not satisfied with the fair hearing decision, you may appeal and request a second fair hearing. If the fair hearing decision ends or reduces your benefits, you may have to repay any benefits you receive while your appeal was pending. You may ask not to receive continued benefits. YOU MAY REPRESENT YOURSELF OR BE REPRESENTED at the hearing by an attorney, friend or anyone else you choose. We cannot pay for your attorney. However, free legal services may be available to you if you qualify. If you fail to appear, or your representative fails to appear at the hearing without good cause, your appeal is considered abandoned and will be dismissed. IF YOU RECEIVE WISCONSIN WELL WOMAN MEDICAID, present your Forward card to your Wisconsin Well Woman Medicaid providers such as, physicians, hospitals, druggist, dentist, etc. Present your Forward card each time you go to a provider. For some services, you may have to pay a copayment to the provider. The amount depends on how much the service costs. Your provider should tell you if a co-payment is required or if a specific service is not covered by Wisconsin Well Woman Medicaid. Your worker will answer any questions you may have about Wisconsin Well Woman Medicaid. IF YOU RECEIVE BENEFITS OR SERVICES, you must follow these rules: · DO NOT give false information or hide information to get or continue to get benefits. · DO NOT trade or sell your Forward card. · DO NOT alter your Forward card to get benefits you are not entitled to receive. · DO NOT use someone else's Forward card. OTHER MEDICAL COVERAGE As a condition of eligibility, you must report to the agency any third party who may be liable to pay for medical care for you. You must cooperate by giving information as requested. This also includes any insurance that may be available through an employee's group health insurance. OVERPAYMENTS You must pay back Medicaid you receive in error under certain circumstances. NON-DISCRIMINATION STATEMENT If you believe you have been discriminated against in any way that relates to applying for Wisconsin Well Woman Medicaid or receiving Wisconsin Well Woman Medicaid services, contact: U.S. Dept. of HHS Regional Manager Office of Civil Rights, Region V 233 N. Michigan Avenue, Suite 240 Chicago, IL 60601 (312) 886-2359 (312) 353-5693 (TTY)

The Department of Health and Human Services and the Department of Health and Family Services are equal opportunity employer and service provider. If you have a disability and need to access this information in an alternate format, or need it translated to another language, please contact (608) 266-3465 or 1-888-701-1251 (TTY). All translation services are free of charge. For civil rights questions call (608) 266-9372 or 1-888-701-1251 (TTY).

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