DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
Wis. Stat. § 49.685
WISCONSIN HEMOPHILIA HOME CARE PROGRAM
FINANCIAL NEED STATEMENT
READ INSTRUCTIONS (F-01187A) 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?
9. Date of Birth
10. Do you have any dependent family members who are also members of the Chronic Disease
If Yes, indicate the names and SSNs of all dependent family members who are members of the Chronic Disease
Name – Dependent Family Member
11. 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)
SECTION 2. RESIDENCY INFORMATION
12. Have you lived in Wisconsin for the last two years?
If no, indicate the date you moved to Wisconsin:
13a. 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.
Alien registration card issued by the United States Citizenship and Immigration Services (USCIS) if you are not a U.S.
Note: If you are unable to provide either of the following documents, you may have your treatment facility social worker
sign the residency verification:
A copy of the most recent rental agreement or property tax bill.
A copy of your Wisconsin driver’s license with current address OR state identification with current address.