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MEDICAID ASSET ASSESSMENT
AST
F-10095 (07/15)
Page 2
SECTION IV – RIGHTS AND RESPONSIBILITIES
I certify, under penalty of false swearing, that all my answers are correct and complete to the best of my
knowledge. I also understand that I may be asked to provide proof of any information given on this
assessment form and that giving false information may subject me to prosecution for fraud. I understand that if
my spouse or I disagree with the findings of this assessment that my spouse or I cannot file for a fair hearing
until my or my spouse’s application for Medicaid benefits has been filed and eligibility determined.
I understand that after a decision has been made on my application for Medicaid, my spouse or I have a right
to appeal the decision, by requesting a fair hearing if we disagree with the amount or the method of computing
the community spouse asset share. We may request a hearing at the county/tribal social or human services
agency where I applied. I may also request a fair hearing by writing to:
Department of Administration
Division of Hearings and Appeals
P.O. Box 7875
Madison, WI 53707-7875
Or by calling
1-608-266-3096
This form can also be downloaded from the Division of Hearings and Appeals website at
SECTION V – SIGNATURE
I understand that if any of the information provided by myself, my spouse or my authorized representative is
incomplete or false, then the amount of the community spouse asset share is not binding in any department
determination and is subject to change.
Two witnesses are required if you sign with an “X”.
SIGNATURE – Resident
Date Signed
SIGNATURE – Community Spouse
Date Signed
SIGNATURE – Witness
Date Signed
SIGNATURE – Witness
Date Signed
RESET FORM
Page 3

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