Form Dph 4818 – Fill Out and Use This PDF

The DPH 4818 form is a critical document for enrollment in the Wisconsin Well Woman Program (WWWP), a state initiative in Wisconsin designed to provide preventive health screening services to underinsured or uninsured women. This comprehensive form gathers personal, insurance, and healthcare provider information from applicants to determine eligibility and facilitate enrollment in the program. To ensure you can take advantage of this valuable resource, fill out the DPH 4818 form by clicking the button below.

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Form Dph 4818 PDF Details

The DPH 4818 form serves as an essential document for the Wisconsin Well Woman Program (WWWP), an initiative by the Department of Health and Family Services within the State of Wisconsin. Directed towards the Division of Public Health under s. 255.075, Wis Stats, and updated last in June 2008, this form is pivotal for enrolling participants seeking preventive health screening services. It meticulously collects personal information, acknowledging the confidentiality protected under Wis. Stats 146.82, and covers a broad spectrum, from demographic details to insurance information, thus ensuring a comprehensive understanding of the applicant's eligibility and needs. Additionally, it includes a client participation agreement, emphasizing informed consent and the conditions of the program, like the coverage of preventive services but not medical treatment services, and stipulates the need for accurate and up-to-date information. The form becomes a crucial step for applicants to access the program's benefits, requiring thorough completion and an understanding of the WWWP's scope, enrollment process, and participant responsibilities. Through sections requesting details on healthcare providers and means of learning about the program, it also offers insights into the participant's healthcare journey and information dissemination effectiveness of the WWWP.

Question	Answer
Form Name	Form Dph 4818
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	Wis, Underinsured, Rm, LCA

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DEPARTMENT OF HEALTH AND FAMILY SERVICES	STATE OF WISCONSIN
Division of Public Health	s. 255.075, Wis Stats.

DPH 4818 (Rev. 06/01/08)

WISCONSIN WELL WOMAN PROGRAM (WWWP) ENROLLMENT

Read instructions on reverse prior to completing this form. Print clearly. Client information in this document is confidential under Wis. Stats 146.82

PERSONAL INFORMATION – Completed by Client

1. Last Name:

2. First Name:

Middle Initial:

Previous Last Name:

5. Street Address:

City:

7. State:

8. Zip:

County of Residence:

10. Native American Tribe:

11. Date of Birth:

(mm/dd/yyyy)

12.

Client Identification No.:

13. Social Security No.: (Optional)

14.

Day Telephone No.: (

)

15. Other/Cell Phone No.:

(

)

16. Mailing Address:

17.

City:

18. State:

19. Zip:

(If different from above)

20.Race: (check all that apply)

21. Ethnicity:

Hispanic / Latina


White	Black / African American
American Indian or Alaska Native
Non-Hispanic		Unknown

Asian Unknown

Native Hawaiian or Other Pacific Islander

22.	Emergency contact, not living with you:					23. Relationship:
24.	Address:		25. City:		26. State:			27. Zip:
28.	Contact Person’s Day Telephone No.: (	)		29. Other/Cell Phone No.:			(	)

INSURANCE INFORMATION – Completed by Client

30.Do you have Medicaid (including Family Planning Waiver)?

32. Do you have health insurance?

Yes

No	31. Do you have Medicare Part B?	Yes
	33. Do you have disability health insurance?

Yes

HEALTH CARE PROVIDER INFORMATION – Completed by Client

34.Do you have a primary health care provider?

36.Clinic Name:

Yes

No 35. If Yes, Name of Provider:

37.Street Address:

41.How did you hear about this program?

	38. City:
WWWP Coordinator	Relative / Friend
Clinic / Health Care Provider		Fair

	39. State:
Radio / TV	Newspaper
Billboard	Bus advertisement

40.Zip:

Brochure / Poster

Other

42.CLIENT PARTICIPATION AGREEMENT

I understand and agree to the following: the Wisconsin Well Woman Program (WWWP) will use the personally identifiable information only for program enrollment, program administration and case management. I give WWWP permission to release my medical information to the Local Coordinating Agency (LCA), other service providers, referral agencies and the State of Wisconsin. I understand that WWWP pays for preventive screening services, but does not pay for medical treatment services. I have seen the current program eligibility criteria and, to the best of my knowledge, my annual income does not exceed them. All of the information I have given is true and correct. I will inform the WWWP LCA if I move or if I no longer wish to participate.

I understand the enrollment is valid for one (1) year from the date signed.

43.	SIGNATURE – Applicant:	44. Date Signed:
45. SIGNATURE – Witness:		46. Date Signed:

Office Use Only

47.

Enrollment

Re-Enrollment

Dis-Enrollment

Date (mm/dd/yyyy):

Deceased

Date of death (mm/dd/yyyy):

48.

Certifying Agency No.:

49. Certifying Agency Name:

0. Enrollment Start Date (mm/dd/yyyy):

51. Enrollment End Date (mm/dd/yyyy):

52.

Age > 35:

Yes

53.

Income < 250% of Federal Poverty Level:

Yes

54.

Uninsured

55.

Underinsured

(See insurance info above)

56.

Translation services needed:

Yes

Language:

58. Household size:

Meets Eligibility Requirements

Eligibility Confirmed By:

61.

62. Printed name:

63. Signature:

FOR DANE COUNTY ONLY - Mail completed form to: WWWP - Public Health, 210 Martin Luther King Jr. Blvd., Rm. 507, Madison, WI 53703-3346

Form Dph 4818 – Fill Out and Use This PDF

Form Dph 4818 PDF Details

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