Form F-01189 - Wisconsin Chronic Renal Disease Financial Need Statement - 2016
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5DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Stat. § 49.68
F-01189 (04/2016)
WISCONSIN CHRONIC RENAL DISEASE PROGRAM
FINANCIAL NEED STATEMENT
READ INSTRUCTIONS (F-01189A) 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 (only to be used if issues with application)
7b. Is email your preferred method of contact?
Yes
No
8. Are you a veteran?
9. Sex
10. Date of Birth
Yes
No
Male
Female
11. Do you have any dependent family members who are also members of the Chronic Disease
Yes
No
Program?
If Yes, indicate the names and SSNs of all dependent family members who are members of the Chronic Disease
Program.
Name – Dependent Family Member
SSN
12. Race / Ethnicity (Optional)
American Indian or Alaska Native
Asian or Pacific Islander
Hispanic (Mexican, Puerto Rican, Cuban, or other Hispanic Culture)
Black (Not of Hispanic Origin)
White (Not of Hispanic Origin)
13. Current Medical Status
Date Status Began
Incenter Hemodialysis
Incenter Peritoneal Dialysis
Home Hemodialysis
Transplant
Home Peritoneal or Continuous Ambulatory Peritoneal Dialysis (CAPD)
SECTION 2. RESIDENCY INFORMATION
14. Have you lived in Wisconsin for the last two years?
Yes
No
If no, indicate the date you moved to Wisconsin:
15a. Applicants age 19 and over should provide copies of the following documents:
•
Last year’s Wisconsin Income Tax return with all attachments.
•
The most recent rental agreement or property tax bill.
•
Wisconsin driver’s license with current address OR state identification with current address.
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