Form F-01185 - Wisconsin Adult Cystic Fibrosis Program Application - 2014 Page 2
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5WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM
Page 2 of 5
APPLICATION
F-01185 (02/14)
16. 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 eligible for 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__________________________________.
17. 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.
18. 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
19. 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
c. Name – Policy Holder
d. Relationship of Policy Holder
c. Name – Policy Holder
d. Relationship of Policy Holder
e. Policy Number
f. Group Policy Number
e. Policy Number
f. Group Policy Number
g. Coverage Begin Date
h. Coverage Termination Date
g. Coverage Begin Date
h. Coverage Termination Date
Indicate whether this insurance covers these services by answering
Indicate whether this insurance covers these services by 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. Prescription Drugs.
Yes
No
n. Prescription Drugs.
Yes
No
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