33.2 Application

33.2.1 SeniorCare Application Introduction

An individual interested in participating in SeniorCare must complete a SeniorCare Application Form (F-10076). An application may be obtained from a local Office on Aging, Senior Center, or Aging Resource Center. Applications may also be printed from the Department of Health Services web site at: http://www.dhs.wisconsin.gov/seniorCare/index.htm . If the applicant 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 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 33.5.2 ID Cards).

SeniorCare applications should be mailed to:

SeniorCare

P.O. Box 6710

Madison, WI 53716-0710

Note: For benefit renewal requirements, see 33.5 SeniorCare Benefit Period.

33.2.2 Application Processing

A valid application for SeniorCare is a SeniorCare Application Form (F-10076) with the applicant’s:

Name, and
Address, and
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 (33.3 SeniorCare Nonfinancial Requirements) and income (33.6 SeniorCare Financial Requirements) information is needed to determine eligibility.

"General Delivery” may be used for a mailing address but can not 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 participants who are requesting establishment of a new benefit period due to a change in circumstances.

33.2.3 Signing the Application

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 power of attorney/durable power of attorney. (Health Care Power of Attorney is not accepted as proof of authority.)

33.2.3.1 Witnessing the Signature

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).

33.2.4 Authorized Representative

An authorized representative may act on behalf of the SeniorCare participant at application and/or reviews, and is authorized to provide information and any documentation that is necessary to establish SeniorCare eligibility.

A SeniorCare applicant may authorize someone to represent him or her by completing the authorized representative form F-10080. (Note: The early version of SeniorCare application included Section V for authorizing a representative. If the 07/02 version of F-10076 is submitted with Section V completed, SeniorCare will accept the authorization of the representative.)

33.2.5 Guardian and Power of Attorney

An applicant is not required to complete the Authorized Representative form F-10080 if a legal guardian or power of attorney (POA) is applying on the SeniorCare applicant’s behalf.

Copies of guardianship or POA documentation will be requested after the SeniorCare application has been submitted. Documentation must be submitted to the SeniorCare Program before information about the applicant or participant will be released to the guardian or POA. A POA may also be authorized for representation by completing the authorization of representation form (F-10080) SeniorCare Authorization of Information in lieu of submitting the POA papers.