State of Wisconsin
Release 21-01 March 29, 2021
An individual interested in participating in SeniorCare must complete a SeniorCare Application form (F-10076). Applications may be printed from the Department of Health Services' SeniorCare web site at: https://www.dhs.wisconsin.gov/seniorcare/apply.htm. Local Aging and Disability Resource Centers may also have copies of the SeniorCare application. If the applicant A person who has submitted a request for coverage for whom no decision has been made regarding eligibility is unsure where to obtain an application or wants to have one mailed to him/her, he or she should call 1-800- 657-2038 (TTY and translation services are available).
A $30 enrollment fee per person is required as a condition of eligibility. If the enrollment fee is not sent with the application, the eligibility begin date could be delayed (See Section 33.3.2 Enrollment Fee).
SeniorCare applications should be mailed to:
P.O. Box 6710
Madison, WI 53716-0710
Note: For benefit renewal requirements, see Section 33.15 Annual Eligibility Renewal.
A valid application for SeniorCare is a SeniorCare Application form (F-10076) with the applicant’s:
Signature (see 33.2.3 Signing the Application) in Section V. Applications that are not signed in Section V of F-10076) will be returned to the applicant.
However, non-financial (see Section 33.3 Nonfinancial Requirements) and income (33.6 Financial Requirements) information is needed to determine eligibility.
"General Delivery” may be used for a mailing address but cannot be used as a residence address.
The presence of a signature on a SeniorCare application indicates intent to apply. When a signed application is received without an enrollment fee, the department will send an enrollment fee request notice to the applicant(s). An application will not be approved until an enrollment fee is received.
When an application is received with an enrollment fee(s) where the applicant(s) has answered "No” to the question "Are you Requesting SeniorCare?”, the department will assume that there is a request for at least one person. When an application is received without the enrollment fee where the applicant’s answer to the question is "No”, the department will follow up with the applicant(s) to determine his or her intent.
The date a valid application is received by the SeniorCare program is the application filing date. Eligibility for SeniorCare will be determined as soon as possible, but not later than 30 days from the date a valid application is received.
A delay in processing the application may occur if there is a delay in obtaining information or in receipt of the enrollment fee necessary for determining eligibility. If a delay occurs, the applicant will be notified in writing that there is a delay in processing the application. The notice will specify the reason for the delay and inform the applicant of his or her right to appeal the delay.
If the initial application is denied and the applicant wishes to reapply, he or she should check the "New Application” box on the application form. "Reapplication” refers to current members who are requesting establishment of a new benefit period due to a change in circumstances.
The applicant must sign the application form in Section V of F-10076 (Section VI of the 07/02 version of F-10076) with his or her signature, a mark or an "X”, unless one of the following signs for him or her:
A guardian of the estate, a guardian of the person and the estate, or a guardian in general.
An authorized representative A person or organization authorized to act on a client's behalf. An authorized representative may be designated by the client and may exercise all the rights and responsibilities of a client..
A power of attorney/durable power of attorney. (Health Care Power of Attorney is not accepted as proof of authority.)
If a SeniorCare applicant signs the application form in Section V of F-10076 with a mark or an "X”, the signature must be witnessed by two individuals. (Section VI of the 07/02 version of F-10076).
An authorized representative may act on behalf of the SeniorCare member at application and/or renewals, and is authorized to provide information and any documentation that is necessary to establish SeniorCare eligibility.
A SeniorCare applicant or member may appoint an individual or an organization as an authorized representative by completing the SeniorCare Authorized Representative form (F-10080).
There can be only one authorized representative at a time for a SeniorCare. There is no time limit on how long a person or organization can act as authorized representative. The appointment of the authorized representative is valid until the applicant or member notifies the agency of a change or removal in writing. SeniorCare authorized representatives can only act on the individual’s behalf for SeniorCare.
Organizations acting as authorized representatives must provide the name and contact information of a person from the organization. Once the organization has been appointed as the authorized representative, anyone from the organization will be able to take action on behalf of the applicant or member (not just the person who signed the form on behalf of the organization). If an organization is only changing the contact person for the organization, the member is not required to complete a new SeniorCare Authorization of Representative form if the organization is going to remain as the authorized representative.
The authorized representative should be familiar with the applicant or member’s household situation and is expected to fulfill their responsibilities to the same extent as the individual being represented. An authorized representative is limited to doing any or all of the following on behalf of the applicant or member:
To change an authorized representative, the member must complete and submit the SeniorCare Authorization of Representative form to the SeniorCare program.
To remove an authorized representative, the member needs to let the SeniorCare program know of the removal in writing. The member does not need to gather additional signatures from the authorized representative or a witness to complete the removal of an authorized representative. Authorized representatives can also request in writing (for example, a signed statement) to be removed if they no longer want to act as the authorized representative. If an authorized representative is requesting to be removed, a signed statement is not needed by the member. An authorized representative designation is valid on a case until a written and signed request is received for removal.
If a SeniorCare applicant or member is represented by a legal guardian of the person and the estate, legal guardian of the estate, legal guardian in general, or conservator, the legal guardian or conservator must appoint the authorized representative. If the SeniorCare applicant or member only has a legal guardian of the person, the applicant or member must appoint the legal guardian of the person as an authorized representative if the member or member would like the legal guardian of the person to act on his or her behalf. If the applicant or member has a power of attorney, the applicant or member can still appoint an authorized representative.
Copies of guardianship or POA documentation must be submitted to the SeniorCare Program before information about the applicant or member can be released to the guardian or POA, unless the POA is the authorized representative. The SeniorCare Authorization of Representative form (F-10080) will be accepted in lieu of the POA papers.
This page last updated
in Release Number: 19-01
Release Date: 4/19/2019
Effective Date: 4/19/2019