Form F-01185 - Wisconsin Adult Cystic Fibrosis Program Application

WISCONSIN ADULT CYSTIC FIBROSIS PROGRAM

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APPLICATION

F-01185 (02/14)

SECTION 7. AGREEMENT AND SIGNATURES FOR ADULT CYSTIC FIBROSIS 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) receipt of completed

application, including verification by the medical director of a certified Wisconsin cystic fibrosis treatment center of having

cystic fibrosis; c) must be 18 years of age or older.

Pursuant to the authority of Wisconsin Statute 49.683 and 49.687 and the rules promulgated thereunder, the Department or

its fiscal agent will, subject to the conditions named, reimburse an approved provider, on behalf of the member, for part of the

cost of medical treatment specifically relating to cystic fibrosis. 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 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.

Wisconsin Administrative Code 154 specifies the methodology for provider reimbursement. Charges in excess of what the

Adult Cystic Fibrosis Program allows are the individual responsibility of the member.

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, judgement, 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 cystic fibrosis, treatment or lack of treatment.

In order to establish my eligibility for state benefits, I authorize the medical facility (25)__________________________

to disclose information relating to my health condition or payment made for my health care to the Adult Cystic

Fibrosis 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 benefits issued through the Wisconsin Chronic Disease Program are eligible for estate recovery as

defined in DHS 154.07(5). 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 154.02(16).

Date Signed

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

Form F-01185 - Wisconsin Adult Cystic Fibrosis Program Application - 2014 Page 4