Form F-01184 - Wisconsin Hemophilia Home Care Program Application - 2014
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5DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
DIVISION OF HEALTH CARE ACCESS AND ACCOUNTABILITY
ss. 49.685 WIS STATS
F-01184 (02/14)
WISCONSIN HEMOPHILIA HOME CARE PROGRAM
APPLICATION
READ INSTRUCTIONS (F-01184A) CAREFULLY BEFORE COMPLETING THIS FORM
SECTION 1. APPLICANT INFORMATION
1. Name – Applicant (Last, First, MI)
2. Social Security Number (SSN)
(optional)
3. Street Address – Applicant
4. Home Telephone Number
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
No
9. Date of Birth
8. Sex
Male
Female
10. Do you have any dependent family members who are also members of the Chronic Disease Program?
Yes
No
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
11. 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)
SECTION 2. RESIDENCY INFORMATION
12. Have you lived in Wisconsin for the last 2 years?
Yes
No
If you answered No, indicate the date you moved to Wisconsin___________________________________________ .
13a. Applicants age 19 and over should provide copies of the
13b. Applicants under the age of 19 should provide copies of the
following documents.
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 driver’s license with current address OR state
identification with current address.
• Alien registration card issued by the ISN if you are not a
identification with current address OR school identification.
• Alien registration card issued by the ISN if you are not a
U.S. citizen.
U.S. citizen.
14. If you do not have these documents, explain why.
SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
15. Do you currently have or have you had Medicare coverage?
Yes
No
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