Form F-01187 - Wisconsin Hemophilia Home Care Program Financial Need Statement - 2016 Page 2
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5WHHCP FINANCIAL NEED STATEMENT
Page 2 of 5
F-01187
13b. Applicants under the age of 19 should provide copies of the following documents:
•
Parent or guardian’s Wisconsin Income Tax return with all attachments for the last year.
•
Parent or guardian’s most recent rental agreement or property tax bill.
•
Wisconsin driver’s license with current address OR state identification with current address OR student ID.
•
Alien registration card issued by USCIS if you are not a U.S. citizen.
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 OR student
ID.
14. If you do not have these documents, explain why.
SECTION 3. MEDICARE, WISCONSIN MEDICAID, BADGERCARE PLUS, AND SENIORCARE INFORMATION
15. Do you currently have or have you had Medicare coverage?
Yes
No
If yes, indicate your Medicare eligibility dates below.
Part A Begin Date
Part B Begin Date
Part D Begin Date
Part A End Date
Part B End Date
Part D End Date
16. Wisconsin law requires applicants must first complete applications for other health care programs if
Yes
No
they may be reasonably eligible given their financial and non-financial circumstances, before
applying to the Wisconsin Chronic Disease Program (WCDP). The department may waive the
requirement for an applicant who requests a waiver for religious reasons under Wis. Stat. §
49.687 (1m) (b). 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.
17. 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 SIGNOFF
This section is to be completed by the social worker if the applicant is not enrolled in Wisconsin Medicaid, BadgerCare
Plus, or SeniorCare.
18. Based on my knowledge of _________________________________________________________, I attest that he or
she is not eligible for the programs listed above. Explain in the space provided below, where applicable, why the
applicant would be denied eligibility.
Medicaid or BadgerCare Plus
SeniorCare
SIGNATURE – Social Worker
Facility Name
Date Signed
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