Form F-01143 - Wisconsin Chronic Renal Disease Program Residency And Health Care Benefits Verification Page 2
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2WCRDP RESIDENCY AND HEALTH CARE BENEFITS VERIFICATION
Page 2 of 2
F-01143
10. Wisconsin law requires applicants must first complete applications for other health care
Yes
No
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?
If yes, indicate your Medicaid, BadgerCare Plus, or SeniorCare identification number below.
11. 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 / FINANCIAL COUNSELOR SIGNOFF
This section is to be completed by a county/facility social worker or financial counselor if the applicant is not enrolled in
Wisconsin Medicaid, BadgerCare Plus, or SeniorCare.
12. Based on my knowledge of _________________________________________________________, I attest that he or
she is not eligible for the programs listed above. Explain in the space provided, where applicable, why the applicant
would be denied eligibility.
Medicaid or BadgerCare Plus
SeniorCare
SIGNATURE – Social Worker
Facility Name
Date Signed
Wisconsin Administrative Rule 152.03 (1) (a) specifies that in order to be eligible for the Chronic Renal Disease Program,
the applicant must be a resident of Wisconsin.
Based on my knowledge, I attest that_______________________________________________ is a resident of
Wisconsin. I have verified that his or her home address is in Wisconsin.
By signing below, I am attesting the member is a Wisconsin resident as set forth in Wis. Admin. Rule 152.02 (25).
SIGNATURE – Social Worker
Date Signed
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