<p>WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10110 (06/15) MAEF MEDICAID / BADGERCARE PLUS ELIGIBILITY CERTIFICATION</p><p>SECTION 1 – AGENCY CONTACT INFORMATION Agency Number Site Code Worker ID</p><p>Worker Contact Information Tried, but unable to process in: Name Phone CARES Portal WiSACWIS</p><p>SECTION 2– CASEHEAD /PRIMARY PERSON INFORMATION Name (last, first, MI) Member ID CARES Case Number Residence County</p><p>Mailing Address. Same as Residence Address? Yes Residence Address (if different than mailing) In Care of In Care of</p><p>Street Address (or P.O. Box if mailing address) Street Address</p><p>City State Zip Code City State Zip Code</p><p>SECTION 3– CASE MEMBER(S) 1. Name (last, first, MI) Member ID SSN New Change Birth date New Change Gender (mm/dd/ccyy) </p><p>Eligibility From Date Eligibility To Date Med Stat Cancel Date Date of Death New Change Remove (mm/dd/ccyy) </p><p>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) </p><p>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) </p><p>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 </p><p>Amount </p><p>Note: Cost share amounts cannot be increased retroactively. Timely notice must be given when a cost share is increased. Comments</p><p>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.</p>