Form F-01187 - Wisconsin Hemophilia Home Care Program Financial Need Statement - 2016 Page 5


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Disease Program necessary for processing claims and verifying services under the program. I agree to notify the
Department or its fiscal agent in writing within 30 days of any change in name, address, income by more than 10
percent, insurance coverage, or family size. I agree to accept responsibility for the program’s copayments and
deductibles. I have read and consent to the above.
I understand that benefits issued through the Wisconsin Chronic Disease Program are eligible for estate
recovery as defined in Wis. Admin. Rule DHS 153.07 (5). I understand that only Wisconsin residents are eligible
for the Chronic Disease Program. By signing this form, I am attesting that I am a Wisconsin resident as set forth
in Wis. Admin. Rule DHS 153.02 (17).
26. SIGNATURE – Applicant (or applicant’s representative if applicant is a minor)
Date Signed


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