Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014 Page 2
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5WISCONSIN CHRONIC RENAL DISEASE PROGRAM
Page 2 of 5
APPLICATION
F-01186 (02/14)
• If you are currently eligible for Medicare, attach a copy of your Medicare card.
• If you are not eligible for Medicare, attach the letter of denial from the Social Security Administration stating the reason you are
not eligible for Medicare. You may disregard this, if your transplant was more than 3 years ago.
18. Were you eligible for Medicare when you received your kidney transplant?
Yes
No
N\A
19. 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 enrolled in 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._______________________________
20. 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.
21. 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
22. 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
d. Relationship of Policy Holder
d. Relationship of Policy Holder
c. Name – Policy Holder
c. Name – Policy Holder
e. Policy Number
f. Group Policy Number
e. Policy Number
f. Group Policy Number
h. Coverage Termination Date
h. Coverage Termination Date
g. Coverage Begin Date
g. Coverage Begin Date
Indicate whether this insurance covers these services by
Indicate whether this insurance covers these services by answering
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. Home Dialysis Supplies.
Yes
No
n. Home Dialysis Supplies.
Yes
No
o. Prescription Drugs.
Yes
No
o. Prescription Drugs.
Yes
No
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