Form F-01185 "Wisconsin Adult Cystic Fibrosis Program Application" - Wisconsin

What Is Form F-01185?

This is a legal form that was released by the Wisconsin Department of Health Services - a government authority operating within Wisconsin. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2014;
  • The latest edition provided by the Wisconsin Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form F-01185 by clicking the link below or browse more documents and templates provided by the Wisconsin Department of Health Services.

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Download Form F-01185 "Wisconsin Adult Cystic Fibrosis Program Application" - Wisconsin

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DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
ss. 49.683 WIS STATS
F-01185 (02/14)
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
APPLICATION
READ INSTRUCTIONS (F-01185A) CAREFULLY BEFORE COMPLETING THIS 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
7a. Email Address (optional, only to be used if issues with application)
7b. Is email your preferred method of
contact?
Yes
No
9. Date of Birth
8. Sex
Male
Female
10. 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 ______________________________________________
SSN
Name ______________________________________________
SSN
11. Race/Ethnicity (Optional)
American Indian or Alaska Native
Asian or Pacific Islander
Hispanic (Mexican, Puerto Rican, Cuban
Black (Not of Hispanic Origin)
White (Not of Hispanic Origin)
or other Hispanic Culture)
SECTION 2. RESIDENCY INFORMATION
12. Have you lived in Wisconsin for the last 2 years?
Yes
No
If you answered No, indicate the date you moved to Wisconsin. __________________________________________
13a. Applicants age 19 and over should provide copies of the
13b. 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
• Wisconsin driver’s license with current address OR state
tax bill.
• Wisconsin driver’s license with current address OR state
identification with current address.
• Alien registration card issued by the INS if you are not a
identification with current address OR school identification.
• Alien registration card issued by the INS if you are not a U.S.
U.S. citizen.
citizen.
14. If you do not have these documents, explain why.
SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
15. Do you currently have or have you had Medicare coverage?
Yes
No
If yes, indicate your Medicare eligibility dates below.
Part A Begin Date _____________
Part B Begin Date ________________
Part D Begin Date ________________
______________
Part A End Date
_____________
Part B End Date
________________
Part D End Date
DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
ss. 49.683 WIS STATS
F-01185 (02/14)
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
APPLICATION
READ INSTRUCTIONS (F-01185A) CAREFULLY BEFORE COMPLETING THIS 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
7a. Email Address (optional, only to be used if issues with application)
7b. Is email your preferred method of
contact?
Yes
No
9. Date of Birth
8. Sex
Male
Female
10. 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 ______________________________________________
SSN
Name ______________________________________________
SSN
11. Race/Ethnicity (Optional)
American Indian or Alaska Native
Asian or Pacific Islander
Hispanic (Mexican, Puerto Rican, Cuban
Black (Not of Hispanic Origin)
White (Not of Hispanic Origin)
or other Hispanic Culture)
SECTION 2. RESIDENCY INFORMATION
12. Have you lived in Wisconsin for the last 2 years?
Yes
No
If you answered No, indicate the date you moved to Wisconsin. __________________________________________
13a. Applicants age 19 and over should provide copies of the
13b. 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
• Wisconsin driver’s license with current address OR state
tax bill.
• Wisconsin driver’s license with current address OR state
identification with current address.
• Alien registration card issued by the INS if you are not a
identification with current address OR school identification.
• Alien registration card issued by the INS if you are not a U.S.
U.S. citizen.
citizen.
14. If you do not have these documents, explain why.
SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
15. Do you currently have or have you had Medicare coverage?
Yes
No
If yes, indicate your Medicare eligibility dates below.
Part A Begin Date _____________
Part B Begin Date ________________
Part D Begin Date ________________
______________
Part A End Date
_____________
Part B End Date
________________
Part D End Date
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
Page 2 of 5
APPLICATION
F-01185 (02/14)
16. 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__________________________________.
17. 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.
18. 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________________________________________________________________________________________________
Facility Name
SIGNATURE – Social Worker
Date Signed
SECTION 5. INSURANCE INFORMATION
19. 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
d. Relationship of Policy Holder
c. Name – Policy Holder
d. Relationship of Policy Holder
e. Policy Number
f. Group Policy Number
e. Policy Number
f. Group Policy Number
g. Coverage Begin Date
h. Coverage Termination Date
g. Coverage Begin Date
h. Coverage Termination Date
Indicate whether this insurance covers these services by answering
Indicate whether this insurance covers these services by answering
each question. Answer each question.
each question. Answer each question.
i. Inpatient Hospital Service.
Yes
No
i. Inpatient Hospital Service.
Yes
No
j. Outpatient Hospital Service.
Yes
No
j. Outpatient Hospital Service.
Yes
No
k. Physician Services.
Yes
No
k. Physician Services.
Yes
No
l. Radiology Services.
Yes
No
l. Radiology Services.
Yes
No
m. Laboratory Services.
Yes
No
m. Laboratory Services.
Yes
No
n. Prescription Drugs.
Yes
No
n. Prescription Drugs.
Yes
No
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
Page 3 of 5
APPLICATION
F-01185 (02/14)
SECTION 6. FINANCIAL INFORMATION
20. Indicate the number of dependent family members; include yourself if you are a dependent family member. _____________________
Average
21. Indicate your current total income by completing items a - m either by
OR
Monthly Totals
Annual Totals
monthly OR annual totals.
________
2 0__ __
2 0 __ __
Month
Year
Year
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.
$
$
22. Do you expect this income to change significantly from month to month or in the next year?
Yes
No
23. If yes, will your income be less or more than the total above?
Less
More
Explain why.
24. On last year’s Wisconsin Income Tax return, what was your total gross family income before taxes? $_______________________
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
Page 4 of 5
APPLICATION
F-01185 (02/14)
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 (25)__________________________
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 DHS 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 DHS 154.02(16).
Date Signed
26. SIGNATURE – Applicant (or applicant’s representative if applicant is a minor)
WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
Page 5 of 5
APPLICATION
F-01185 (02/14)
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.
27. Name – Patient (Last, First, MI)
28. Patient’s primary diagnosis
(Use ICD-9-CM code)
Date Patient was diagnosed with cystic fibrosis _________________________ .
29.
30. Name – Treating Facility
31. Wisconsin Medicaid or BadgerCare Plus Provider
identification number of facility
32. Address – Treating Facility
I certify that the above patient has been diagnosed to have cystic fibrosis.
33. 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.