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Form F-01143 - Wisconsin Chronic Renal Disease Program Residency And Health Care Benefits Verification

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Health Care Access and Accountability

Wis. Stat. § 49.68

F-01143 (02/2016)

WISCONSIN CHRONIC RENAL DISEASE PROGRAM

RESIDENCY AND HEALTH CARE BENEFITS VERIFICATION

Wisconsin Chronic Disease Program (WCDP) requires the information requested in this form to enable WCDP to

determine member eligibility for other health care programs if the member is unable to provide a copy of either of the

following documents:

•

A copy of his or her most recent rental agreement OR property tax bill.

•

A copy of his or her Wisconsin driver’s license with current address OR state identification with current address OR

student ID (only for applicants under age 19).

This form should be completed by a county/facility social worker or transplant clinic financial counselor. The social

worker/financial counselor will fill out this form, sign it, and send it to the member. After the member has the completed

form, it should be sent to WCDP with the member’s completed Financial Need Statement. It is the member’s responsibility

to ensure that sections 1,2,5,6, and 7 on the Financial Need Statement are completed. Do not mail the Financial Need

Statement to the social worker/financial counselor. The use of this form is mandatory if the member is unable to supply

the documents listed above. Failure to supply the information requested on the Residency and Health Care Benefits

Verification form may result in a denial of WCDP eligibility. Provision of your Social Security Number (SSN) is voluntary;

however, your SSN is one of the unique identifiers used to identify you as a unique person in our claim system. Personally

identifiable information is confidential and is used for purposes directly related to WCDP administration.

If you are a dialysis or transplant patient and do not know who your social worker is, you may contact your treatment

facility.

SECTION 1. SOCIAL WORKER / FINANCIAL COUNSELOR INFORMATION

1. Name – Social Worker / Financial Counselor

2. Telephone Number

3. Facility Name

4. Facility Street Address

5. City, State, Zip Code

SECTION 2. MEMBER INFORMATION

6. Name – Applicant

7. SSN or WCDP Identification Card Number

SECTION 3. MEDICARE, MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION

8. Do you currently have or have you had Medicare coverage?

Yes

Part A Begin Date

Part B Begin Date

Part D Begin Date

Part A End Date

Part B End Date

Part D End Date

9. Were you eligible for Medicare when you received your kidney transplant?

Yes

N/A

Form F-01143 - Wisconsin Chronic Renal Disease Program Residency And Health Care Benefits Verification

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