WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10110 (06/15) MAEF MEDICAID / BADGERCARE PLUS ELIGIBILITY CERTIFICATION

SECTION 1 – AGENCY CONTACT INFORMATION Agency Number Site Code Worker ID

Worker Contact Information Tried, but unable to process in: Name Phone CARES Portal WiSACWIS

SECTION 2– CASEHEAD /PRIMARY PERSON INFORMATION Name (last, first, MI) Member ID CARES Case Number Residence County

Mailing Address. Same as Residence Address? Yes Residence Address (if different than mailing) In Care of In Care of

Street Address (or P.O. Box if mailing address) Street Address

City State Zip Code City State Zip Code

SECTION 3– CASE MEMBER(S) 1. Name (last, first, MI) Member ID SSN New Change Birth date New Change Gender (mm/dd/ccyy)

Eligibility From Date Eligibility To Date Med Stat Cancel Date Date of Death New Change Remove (mm/dd/ccyy)

2. Name (last, first, MI) Member ID SSN New Change Birth date New Change Gender (mm/dd/ccyy) Eligibility From Date Eligibility To Date Med Stat Cancel Date Date of Death New Change Remove (mm/dd/ccyy)

3. Name (last, first, MI) Member ID SSN New Change Birth date New Change Gender (mm/dd/ccyy) Eligibility From Date Eligibility To Date Med Stat Cancel Date Date of Death New Change Remove (mm/dd/ccyy)

Waiver Cost Share Institutional Medicaid Liability Waiver Cost Share Group B Institutional Patient Liability Waiver Cost Share Group B Plus Begin Date Group C Waiver Spenddown End Date Begin Date Amount End Date

Amount

Note: Cost share amounts cannot be increased retroactively. Timely notice must be given when a cost share is increased. Comments

I certify that this certification represents the official authorized SIGNATURE or NAME of person submitting this cerification Date action of the State Dept of Health Services in accordance with § 49.95, 49.96, 49.47 and 49.665, Wisconsin statues.