F.wi.gov Complete this form to provide your Medicare information to ETF. You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. If not enrolled, you will be liable for the claims Medicare would have paid. All Persons Insured Under Your Group Health Insurance Policy Complete this information for all persons on your group health insurance policy. Include everyone on your plan, including yourself. See page 2 for.
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How to fill out the WI ET-4307 online
Completing the WI ET-4307 form online is essential for providing your Medicare information to the Wisconsin Department of Employee Trust Funds. This guide offers clear, step-by-step instructions to assist users in accurately filling out the form, ensuring compliance and avoiding potential claims issues.
Follow the steps to complete the WI ET-4307 online.
- Click the 'Get Form' button to obtain the WI ET-4307 form and open it in your preferred document editor.
- Fill in your personal information, including your name and contact details. Ensure all fields are completed accurately to avoid delays.
- Provide the Medicare numbers for you and all insured dependents on your group health insurance policy. Write 'none' if not enrolled in Medicare.
- Indicate Medicare eligibility reasons (age, disability, or ESRD) for each person listed, and ensure that the effective dates are clearly recorded.
- Complete the section regarding prescription drug coverage, specifying if you will use the state’s Navitus MedicareRX plan.
- Review the Important Medicare Information section and attest to your understanding by signing and dating the form.
- Attach a copy of your Medicare card or any other accepted documentation that verifies your Medicare enrollment and effective dates.
- Finally, save your changes, and either download or print the completed form for submission. You can then share it via mail or fax to the provided ETF address.
Complete your documents online today for a seamless process.
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