
RCare Prescription Drug Program. This is not an application for any other benefit program. For help with this form, contact the SeniorCare Customer Service Hotline at 1-800-657-2038, Monday through Friday, 8:00 a.m. to 6:00 p.m. (TTY and translation services are available.) Help may also be available at your local aging office, senior center, or aging resource center. Information is available on the Wisconsin Department of Health Services (DHS) website at: dhs.wisconsin.gov/seniorcare. IMPORTANT.
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How to fill out the WI F-10076A online
Filling out the WI F-10076A form correctly is essential for your application to the SeniorCare Prescription Drug Program. This guide provides clear and detailed instructions that will help you complete each section of the form online with confidence.
Follow the steps to complete the WI F-10076A application.
- Press ‘Get Form’ button to access the application form and open it in your preferred editor.
- Fill in your personal information, including your name, address, and contact details. Ensure all entries are made clearly using CAPITAL letters and blue or black ink.
- Provide information about your spouse if they are living with you. Complete the 'Spouse Information' section fully, as their income may affect your SeniorCare eligibility.
- Indicate your residency status in Wisconsin and confirm your citizenship or legal residency status. If applicable, attach your alien registration card.
- Complete the income section accurately. Provide estimated gross annual income for you and your spouse from all sources, using the worksheet provided at the end of the instructions if needed.
- Sign the application to validate it. If you are submitting on behalf of someone else, ensure their representative signs the form as well.
- Enclose the appropriate enrollment fee of $30 for one applicant or $60 for two applicants. Do not send cash, and ensure to include the names of all applicants on your payment.
- Review the entire application to ensure all fields are completed and accurate, then submit it by mailing it to the address provided on the form.
Start your application process online today for the SeniorCare program.
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