Get Wi Et-4307 2024-2026

The WI ET-4307 form is essential for providing your Medicare eligibility information to the Wisconsin Department of Employee Trust Funds. This guide will help you complete the form accurately and efficiently, ensuring all necessary details are submitted correctly.

Follow the steps to successfully complete the WI ET-4307 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the form by entering your name and the names of all insured dependents covered by your group health insurance policy. Ensure that the Medicare number and effective dates are written clearly.
3. Provide your Medicare effective dates for both Hospital Part A and Medical Part B. If you or any dependent is not enrolled in Medicare, indicate this by writing 'none.'
4. Select the reason for eligibility for each person listed (age, disability, or end-stage renal disease). Make sure to provide accurate information for each section.
5. Indicate whether you will use the state's Navitus MedicareRX plan for prescription drug coverage. If you plan to use another plan, please specify it.
6. Read the Important Medicare Information section carefully. Ensure you understand the implications of enrolling or not enrolling in Medicare for both yourself and your dependents.
7. Sign and date the form, entering your printed name, telephone number, and mailing address. Ensure the Member ID or Social Security Number is also provided.
8. Attach a copy of your Medicare card or documentation from Medicare or Social Security that includes your Medicare numbers and effective dates.
9. Make a copy of the completed form for your records. Once finalized, return the original form by mail or fax to ETF.

Complete and submit your documents online to ensure your Medicare information is processed promptly.