Form F-13033 - Probate Claims Notice
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Medicaid Services
F-13033 (09/2017)
PROBATE CLAIMS NOTICE
Completion of this form is required according to Wis. Stat. §§ 859.07 (2), 867.01 (3)(d), and 867.02 (2)(d). Personally identifiable
information will only be used in the administration of the Estate Recovery and Wisconsin Funeral and Cemetery Aids Section and will
not be disclosed to other agencies. Consequences of failure to complete this form are covered under Wis. Stat. §§ 859.02 and 865.17.
In the matter of the estate of:
STATE OF WISCONSIN, Circuit Court Branch
Name – Deceased Member
County of Probate
Social Security Number (SSN)
Type of Probate
Date of Death
File Number
Date of Birth
Final Date to File Claims
Check here if the deceased member has received one or more of the following:
•
Medicaid or BadgerCare Plus benefits under Wis. Stat. ch. 49
•
Medicaid or non-Medicaid benefits under a long-term care program as defined in Wis. Stat. § 49.496 (bk)s
•
Medicaid Purchase Plan (MAPP) benefits under Wis. Stat. § 49.472
•
Wisconsin Community Options Program (COP) benefits under Wis. Stat. § 46.27
•
Wisconsin Chronic Disease Program (WCDP) benefits under Wis. Stat. §§ 49.68 through 49.685
Check here if the predeceased spouse of the deceased member has received one or more of the following, and
provide the requested information below (if more than one spouse, attach an additional sheet):
•
Medicaid or BadgerCare Plus benefits under Wis. Stat. ch. 49
•
Medicaid or non-Medicaid benefits under a long-term care program as defined in Wis. Stat. § 49.496 (bk)
•
Medicaid Purchase Plan (MAPP) benefits under Wis. Stat. § 49.472
•
Wisconsin Community Options Program (COP) benefits under Wis. Stat. § 46.27
•
Wisconsin Chronic Disease Program (WCDP) benefits under Wis. Stat.§§ 49.68 through 49.685
Name – Predeceased Spouse
SSN – Predeceased Spouse
Date of Birth – Predeceased Spouse
Date of Death – Predeceased Spouse
Disclosure of the SSN of a Medicaid member is mandatory, per 42 U.S.C. 1320b-7. Disclosure of the SSN of a
non-Medicaid member is voluntary. The SSN will only be used for the identification of Medicaid, BadgerCare
Plus, COP, and WCDP members and for the administration of the Estate Recovery and Wisconsin Funeral and
Cemetery Aids Section.
Name – Personal Representative/Petitioner
Name – Attorney
Mailing Address
Mailing Address
City
State
Zip Code
City
State
Zip Code
MAILING: This form must be sent to the Department of Health Services Estate Recovery and Wisconsin Funeral and
Cemetery Aids Section by certified mail at least 30 days prior to the date set under Wis. Stat. § 859.1, or as soon as
possible after filing summary petitions under Wis. Stat. § 867.01 or 867.02.
Mail a copy to:
RESET FORM
Wisconsin Department of Health Services
Division of Medicaid Services
Estate Recovery and Wisconsin Funeral and Cemetery Aids Section
PO Box 309
Madison WI 53701-0309
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