Form F-01186 - Wisconsin Chronic Renal Disease Program Application

WISCONSIN CHRONIC RENAL DISEASE PROGRAM

Page 4 of 5

APPLICATION

F-01186 (02/14)

SECTION 7. AGREEMENT AND SIGNATURES FOR CHRONIC RENAL DISEASE PROGRAM 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) payment of Medicare part B

premiums, if eligible for Medicare; c) receipt of a completed application, including verification by a nephrologist or transplant

surgeon from an approved facility of having end stage renal disease. End stage renal disease is defined in Administrative

Code 152 as “That stage of renal impairment which is virtually irreversible, and requires a regular course of dialysis or kidney

transplantation to maintain life.”

Pursuant to the authority of Wisconsin Statute 49.68 and 49.687 and the rules promulgated thereunder, the Department or its

fiscal agent will, subject to the conditions named, reimburse an approved dialysis or transplant facility in the state or a dialysis

or transplant center which is approved as such in a contiguous state, on behalf of the member, for part of the cost of medical

treatment specifically relating to chronic renal disease. 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 that 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.

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, judgment, 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 chronic renal disease, treatment or lack of treatment.

In order to establish my eligibility for state benefits, I authorize the medical facility (29) ________________________

to disclose information relating to my health condition or payment made for my health care to the Chronic Renal

Disease 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 if I have not had a kidney transplant and I no longer require a regular course of dialysis to maintain

life, I will not be eligible for benefits of the Wisconsin Chronic Renal Disease Program as of the date of my last

dialysis. I will not be eligible for benefits until such time that I receive a kidney transplant or require a regular course

of dialysis to maintain life. I also understand that if I am eligible for Medicare Part B, I must continue to pay Part B

premiums in order to remain eligible for the Chronic Renal Disease Program.

I understand that benefits issued through the Wisconsin Chronic Disease Program are eligible for estate recovery as

defined in DHS 152.065(7). 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 152.02(25).

Date Signed

30. SIGNATURE – Applicant (or applicant’s representative if applicant is a minor)

Form F-01186 - Wisconsin Chronic Renal Disease Program Application - 2014 Page 4

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