Form F-01187 - Wisconsin Hemophilia Home Care Program Financial Need Statement - 2016 Page 4
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5WHHCP FINANCIAL NEED STATEMENT
Page 4 of 5
F-01187
Average Monthly Totals
Annual Totals
$
$
i. Unemployment compensation and/or worker’s compensation
$
$
j. Maintenance, alimony, and/or child support
$
$
k. Nontaxable interest (federal, state, or municipal bonds)
$
$
l. Nontaxable deferred compensation
$
$
m. Total Monthly OR Yearly income
22. Do you expect this income to change significantly from month to month or in the next year?
Yes
No
23. If yes, will your income be less or more than the total above?
Yes
No
Explain why.
24. On last year’s Wisconsin Income Tax return, what was your total gross family income
$
before taxes?
SECTION 7. AGREEMENT AND SIGNATURES FOR HEMOPHILIA HOME CARE APPLICANTS
Eligibility for state reimbursement exists only insofar as certified by the Department of Health Services (herein called the
Department) or its fiscal agent upon: (a) receipt of completed application, including verification by the physician director of
the member’s successful participation in a hemophilia home care or self-infusion training program and maintenance
program; and (b) existence of a written agreement, as designated by the Department or its fiscal agent, between the
patient and a certified comprehensive treatment center for compliance with the maintenance program.
Pursuant to the authority of Wis. Stat. §§ 49.685 and 49.687 and the rules promulgated thereunder, the Department or its
fiscal agent will, subject to the conditions named, reimburse a certified comprehensive hemophilia treatment center or an
approved source, on behalf of the member, for part of the cost of hemophilia home care blood products and infusion
supplies. Reimbursement will be made only for that portion of the allowable cost of home care blood products and infusion
supplies remaining after all payment from other state programs, federal programs, and private health insurance coverage
has been received and the member’s liability and deductibles have been determined. The member’s liability and
deductibles will be based on income and family size.
Wisconsin Administrative Code ch. DHS 153 specifies the methodology for provider reimbursement. Charges in excess
of what the Hemophilia Home Care Program allows are the individual responsibility of the member.
If insufficient aid is available from other sources, the state shall pay the difference between the allowable cost and the
sum of payment received and member liability and deductibles. State payment shall be appropriately reduced if federal,
state, private, or other health insurance becomes available during the benefit period. The member must inform the
Department or its fiscal agent of all health insurance coverage and eligibility date.
The Department, the State of Wisconsin, and its officers or agents are released and discharged of and from all manner of
action and actions, cause and causes of actions, suits, sums of money, judgment, claims, and demands whatsoever in
law or in equity which the claimant, or his or her heirs, executors, or assignees might have, or may hereinafter have, by
reason of any injury or worsening of condition or death of the member due to treatment of hemophilia or lack of treatment.
In order to establish my eligibility for state benefits, I authorize the medical facility
(25)
to disclose information relating to my health condition or payment
made for my health care to the Hemophilia Home Care Program.
I certify, to the best of my knowledge, all information provided on this form is true, correct, and complete. I
understand that I will be denied reimbursement if I withhold information, provide inaccurate information, or
refuse to provide information. I authorize release of any medical and financial information, including certification
for general assistance, Wisconsin Medicaid, BadgerCare Plus, SeniorCare, or Medicare, to the Wisconsin Chronic
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