Fill Out a Valid Wisconsin F 10138 Template Edit Form Online

Fill Out a Valid Wisconsin F 10138 Template

The Wisconsin F 10138 form is a crucial document used as a supplement to the FoodShare Wisconsin Application. It is specifically for individuals applying for both FoodShare Wisconsin and BadgerCare Plus. Completing this form accurately ensures that you receive the necessary benefits for you and your family.

Don't delay in filling out the form. Click the button below to get started.

Edit Form Online
Article Structure

The Wisconsin F-10138 form, also known as the BadgerCare Plus Supplement to FoodShare Wisconsin Application, plays a crucial role for individuals applying for both FoodShare and BadgerCare Plus. This form is designed to gather essential information about the applicant, including personal details, household composition, and insurance coverage. Applicants must provide their name, address, and details about any pregnant household members. Additionally, the form requires information about existing or previous health insurance, including policyholder details and coverage status. A signature at the end of the form signifies understanding of the rights and responsibilities associated with the application process. It is vital for applicants to be aware that they must report any changes in their information within ten days. This form not only facilitates access to necessary health services but also ensures compliance with state regulations. Understanding the F-10138 form is key to navigating the application process efficiently and effectively.

Listed Questions and Answers

  1. What is the purpose of the Wisconsin F 10138 form?

    The Wisconsin F 10138 form, also known as the BadgerCare Plus Supplement to FoodShare Wisconsin Application, is designed for individuals applying for both FoodShare Wisconsin and BadgerCare Plus. This form collects essential information to determine eligibility for these programs.

  2. Who needs to complete this form?

    Any individual applying for FoodShare Wisconsin and BadgerCare Plus must complete this form. It is crucial for those who are part of a household that includes a pregnant member or has medical insurance coverage.

  3. What information is required in Section I of the form?

    In Section I, applicants must provide their full name and address, including street, city, state, and zip code. This information helps identify the applicant and establish residency, which is a requirement for eligibility.

  4. How do I report if a household member is pregnant?

    Section II of the form addresses pregnancy. Applicants should indicate whether any household member is pregnant by selecting 'Yes' or 'No.' If applicable, they must provide the name of the pregnant individual and the expected due date. For multiple births, the number of babies should also be listed.

  5. What should I include in the insurance section?

    In Section III, applicants must disclose any medical or health insurance coverage they or their household members have had in the past three months. This includes the policyholder's name, policy number, the insurance company's details, and any changes in coverage status.

  6. What are my responsibilities after signing the form?

    By signing the form, applicants acknowledge their responsibility to report any changes in their circumstances within ten days. This includes changes in household composition, income, or insurance coverage. Cooperation with local agencies in providing necessary information is also required.

  7. What if I disagree with a decision regarding my application?

    If an applicant disagrees with any action taken on their BadgerCare Plus or FoodShare application, they have the right to request a Fair Hearing. This can be done by contacting the Wisconsin Department of Administration Division of Hearings and Appeals through mail or phone.

  8. How can I file a complaint regarding discrimination?

    Individuals who believe they have experienced discrimination may file a complaint with the Wisconsin Department of Health Services or the U.S. Department of Health and Human Services Office for Civil Rights. Contact details for both agencies are provided in the form, ensuring that individuals know their rights and how to seek assistance.

Key takeaways

When filling out the Wisconsin F 10138 form, there are several important points to keep in mind to ensure a smooth application process for BadgerCare Plus and FoodShare Wisconsin.

  • Complete the Form Accurately: Ensure all sections are filled out completely and accurately. This includes providing your name, address, and details about your household.
  • Pregnancy Information: If any household member is pregnant, provide the necessary details, including the due date and the number of expected babies.
  • Insurance Details: Disclose any medical or health insurance coverage you or your household members have had in the last three months. Include the policyholder's name and the insurance company's details.
  • Reporting Changes: You must report any changes to your information within 10 days. This includes changes in household composition, income, or insurance status.
  • Understanding Your Rights: By signing the form, you acknowledge that the local agency can request necessary information for administering BadgerCare Plus. This may include information from various sources, such as employers or financial institutions.
  • Appeal Process: If you disagree with any decisions made regarding your application or benefits, you have the right to request a Fair Hearing. This can be done by contacting the Wisconsin Department of Administration.
  • Confidentiality and Compliance: Your information will be kept confidential and used solely for the purposes of administering the program. You can reach out for civil rights questions or file a complaint if you feel your rights have been violated.

By keeping these key points in mind, you can navigate the application process with greater confidence and clarity.

Document Overview

Fact Name Fact Description
Form Purpose The Wisconsin F-10138 form serves as a supplement to the FoodShare Wisconsin Application, specifically for those applying for both FoodShare and BadgerCare Plus.
Applicant Information Section I of the form requires applicants to provide their name and address, ensuring that the local agency can verify identity and residency.
Pregnancy Inquiry Section II asks whether any household member is pregnant, allowing for additional benefits that may be available during pregnancy.
Insurance Information Section III gathers information about existing or previous medical insurance, including policy details and coverage status, which is crucial for determining eligibility.
Legal Authority The form is governed by Wisconsin Statute s. 49.45 (19), which mandates that benefits for medical care under a policy will be assigned to the state during BadgerCare Plus enrollment.
Reporting Changes Applicants must report any changes to their information within ten days, ensuring that the agency has the most current data for accurate benefit determination.
Rights and Responsibilities By signing the form, applicants acknowledge their rights and responsibilities, including the obligation to cooperate with information requests from the Department of Health Services.
Fair Hearing Process Applicants have the right to appeal decisions regarding their application or ongoing benefits by requesting a Fair Hearing through the Wisconsin Department of Administration.

Browse Other Documents

Functional Screening - The F 00366 ensures that accurate and up-to-date information guides care decisions.

Wi State Tax Form - The WT-7 form is essential for maintaining compliance with Wisconsin withholding tax requirements.

Having a Durable Power of Attorney is crucial for individuals in Ohio, as it ensures that a trusted person can make important decisions if they are unable to do so themselves. To create this legal document, it is essential to use reliable resources, such as Ohio PDF Forms, which provide clear guidance and templates to help in the process.

Wisconsin Doa 3009 - If driving is required, volunteers must complete additional vehicle use agreements and training.

Misconceptions

Understanding the Wisconsin F 10138 form can be crucial for those applying for both FoodShare Wisconsin and BadgerCare Plus. However, several misconceptions can lead to confusion. Here are four common misconceptions explained:

  • Only one form is needed for both programs. Many people believe that the F 10138 form is a standalone application. In reality, it is a supplement that must accompany the main FoodShare Wisconsin application.
  • The form is only for pregnant individuals. Some applicants think that this form is exclusively for those who are pregnant. While it does include questions related to pregnancy, it is designed for all applicants seeking benefits from both programs.
  • Insurance information is not necessary. A common misunderstanding is that providing insurance details is optional. In fact, the form requires you to disclose current or recent insurance coverage, as this information is essential for determining eligibility.
  • Submitting the form is the final step. Many believe that once they submit the F 10138 form, their application process is complete. However, applicants must also report any changes in their information within 10 days to ensure their benefits remain accurate and uninterrupted.

By clarifying these misconceptions, individuals can better navigate the application process and ensure they meet all requirements for assistance.

Form Sample

WISCONSIN DEPARTMENT OF HEALTH SERVICES

Division of Health Care Access and Accountability F-10138 (07/08)

APP

BADGERCARE PLUS SUPPLEMENT TO FOODSHARE WISCONSIN APPLICATION

This form is used as a supplement to the FoodShare Wisconsin Application. Complete this form only if you are applying for FoodShare Wisconsin and BadgerCare Plus.

SECTION I – APPLICANT INFORMATION

Applicant Name (First, MI, Last)

Applicant Address (Street, City, State, Zip Code)

SECTION II – PREGNANCY (Add a second sheet of paper, if more room is needed.)

Is any member of your household pregnant? Yes No

Name of pregnant woman

Due date

If multiple births are expected, list number of babies.

SECTION III – INSURANCE

Does anyone have medical or health insurance now, or in the previous three months?

Yes

No

Policyholder’s name

Policy number

Begin date

Name and address of insurance company

Who is or was covered under this policy?

Family Member’s Name(s):

Has this coverage ended in the last three months?

If yes, what is the date the coverage ended?

Why did the coverage end?

Yes

No

Is/was this insurance provided by an employer?

If yes, what is the employer’s name?

Yes

No

Does this insurance cover services from a doctor?

Yes

No

SECTION V – SIGNATURE

I understand that as a condition of enrollment in BadgerCare Plus, I must report to the local county or tribal agency any other person(s) that may be liable to pay for medical care for my family and me. I must also cooperate by giving information to assist the local county or tribal agency in pursuing payment from any other person(s). I understand that any benefits for the cost of medical care which are available under a policy will be assigned to the State by law (s. 49.45 (19), WI Statutes.) during any period of BadgerCare Plus enrollment. I understand that within 10 days I must report any changes in all of the above information. The information given above is true and complete to the best of my knowledge.

SIGNATURE – Applicant or Authorized Representative

Date Signed

BADGERCARE PLUS SUPPLEMENT TO FOODSHARE WISCONSIN APPLICATION

F-10138 (07/08)

RIGHTS AND RESPONSIBILITIES

Your signature on the application means that you understand and acknowledge that the local county or tribal agency and the state Department of Health Services is authorized to request any information that is appropriate and necessary for the proper administration of BadgerCare Plus as authorized under Wisconsin law.

Any person, including any financial institution, credit reporting agency, employer, or educational institution, is authorized to release this information, according to Wisconsin Statute s. 49.22(2m)(a): “The Department may request from any person in this state information it determines appropriate and necessary for the administration of this section, ss.49.141 to 49.161, 49.19, 49.46, 49.468 and 49.47 and programs carrying out the purposes of 7 USC 2011 to 2029. Unless access to the information is prohibited or restricted by law, or unless the person has good cause, as determined by the Department in accordance with federal law and regulations, for refusing to cooperate, the person shall make a good faith effort to provide this information within 7 days after receiving a request under this paragraph. Except as provided in subs. (2p) and (2r) and subject to sub.(12), the Department or the county child support agency under s.59.53(5) may disclose information obtained under this paragraph only in the administration of this section, ss.49.141 to 49.161, 49.19, 49.46 and 49.47 and programs carrying out the purposes of 7 USC 2011 to 2029. Employees of the department or a county child support agency under s.59.53(5) are subject to s.49.83.”

You have the right to appeal any action taken concerning your BadgerCare Plus, or Family Planning services application or on going benefits that you do not agree with by requesting a Fair Hearing. You may request a Fair Hearing by calling or writing to:

Wisconsin Department of Administration

Division of Hearings and Appeals

P.O. Box 7875

Madison, WI 53707-7875

Telephone: (608) 266-3096

You can download the “Request For a Fair Hearing” form from the Division of Hearing and Appeals Web site at http://dha.state.wi.us/home/.

You may also contact your local agency and ask for a Fair Hearing verbally or in writing.

The Department of Health Services (DHFS) is an equal opportunity employer and service provider. For civil rights questions, CALL (608) 266-9372 (voice) or (888) 701-1251 (TTY).

To file a complaint of discrimination by contacting either the:

•Wisconsin Department of Health Services (DHFS)

Affirmative Action and Civil Rights Compliance Office

1 W. Wilson, Room 555

Madison, WI 53707-7850

Telephone: (608) 266-9372 (Voice); (888) 701-1251 (TTY)

Fax: (608) 267-2147

•U.S. Department of Health and Human Services Office for Civil Rights – Region V 233 N. Michigan Avenue

Suite 240 Chicago, IL 60601

Telephone: (312) 886-5077 (voice) or (312) 353-5693 (TTY)