Example Income Calculation Worksheet printable pdf download

Example Income Calculation Worksheet

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

Section 49.688, Wis. Stats.

F-10076A (09/11)

Instructions for Application Form

The SeniorCare application form is only for persons applying for the SeniorCare Prescription Drug

Program. This is not an application for any other benefit program.

For help with this form, contact the

SeniorCare Customer Service Hotline at 1-800-657-2038

(TTY and translation services are available.)

Help may also be available at your local aging office, Senior Center or aging resource center.

Information is available on the Department of Health Services’ web site at:

dhs.wisconsin.gov/seniorcare.

IMPORTANT INFORMATION

• Your application date is the date the completed and signed application form is received by the

SeniorCare program. A decision on your SeniorCare enrollment will be mailed to you within 4-6

weeks. Applications that are not complete or signed will not be processed and will be returned to

you.

• Enclose the $30 enrollment fee for each applicant ($60 if you and your spouse are both requesting

SeniorCare). Your enrollment begin date may be delayed if your full enrollment fee is not received

at the time of your application. If you are not able to enroll in SeniorCare, your enrollment fee will

be returned within 6-8 weeks.

• Complete, sign and mail the application form with the enrollment fee to the address on the form.

• If you wish to authorize a representative to apply for you, contact the SeniorCare Customer Service

Hotline at 1-800-657-2038. The appropriate form and information will be mailed to you.

HOW TO USE THIS FORM

1. Print CLEARLY using CAPITAL letters. Use ONLY blue or black ink. Shade in the circles next to

the appropriate answers by coloring in the circles completely.

2. Complete both sides of the application and submit the appropriate enrollment fee. If your

application is not complete or correct, a SeniorCare Customer Service Representative may contact

you for more information. This may cause a delay in the processing of your SeniorCare application.

3. Provide information on the application form for you and your spouse (if you have a spouse living in

your household). Do not include information about other persons in your household.

Example Income Calculation Worksheet