Form F-01186 - Wisconsin Chronic Renal Disease Program Application

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY

ss. 49.68 WIS STATS

F-01186 (02/14)

WISCONSIN CHRONIC RENAL DISEASE PROGRAM

APPLICATION

READ INSTRUCTIONS (F-01186A) CAREFULLY BEFORE COMPLETING THIS FORM

SECTION 1. APPLICANT INFORMATION

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

9. Sex

10. Date of Birth

8. Are you currently receiving veteran health care benefits?



Male

Female

Yes



11. Do you have any dependent family members who are also members of the Chronic Disease Program?

Yes

If Yes, indicate the names and Social Security Numbers (SSN) of all dependent family members who are members of the Chronic

Disease program.

Name ________________________________________________

SSN

Name ________________________________________________

SSN

12. 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)

13. Current Medical Status



Incenter Hemodialysis

Home Hemodialysis

Transplant



Incenter Peritoneal Dialysis

Home Peritoneal or CAPD

Date this status began__________________

SECTION 2. RESIDENCY INFORMATION



14. Have you lived in Wisconsin for the last 2 years?

Yes

If you answered No, indicate the date you moved to Wisconsin. _________________________________________

15a. Applicants age 19 and over should provide copies of the

15b. Applicants under the age of 19 should provide copies of the

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

• Wisconsin driver’s license with current address OR state

property tax bill.

• Wisconsin drivers 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. citizen.

• A copy of your Medicare card, unless you are exempt.

U.S. citizen.

16. If you do not have these documents, explain why.

SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION



17. Do you currently have or have you had Medicare coverage?

Yes

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

Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014

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